Pulmonary Associates of Charleston, PLLC, et al. v. Greenway Health, LLC

Case No. 3:19-cv-167-TCB

Northern District of Georgia

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Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

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CLAIM FORM

Please click the link for GENERAL INSTRUCTIONS

Instructions: You can submit this form by mail or file claims online. The deadline to submit or postmark a claim is November 1, 2021

Mail claims and supporting documentation to:

Greenway EHR Settlement
1650 Arch Street, Suite 2210
Philadelphia, PA 19103

Please read the Class Notice regarding the Settlement carefully before filling out this form. Terms in this Claim Form are defined in the Class Notice and the Settlement Agreement.

Note: If you are submitting claims for more than one Greenway product, please fill out a separate form for each product.

I. GENERAL QUESTIONS

Question 6: Which Greenway Product Does This Claim Form Concern? (Select only one—if you are submitting claims for more than one product, please fill out a separate form for each product.)

Question 7: Current Mailing Address for the Greenway Customer

* Required Fields
II. QUESTIONS RELATED TO AUTOMATIC PAYMENTS

Question 1: Records possessed by Greenway indicate that your practice purchased and used a Greenway Prime Suite or Intergy EHR between Min Date - Max Date.

Do you agree the information provided is accurate?

Question 2: If you answered No to the previous question, please select the years during which you believe you used that Greenway EHR(s). (Select as many as apply.)

III. CLAIMS FOR ADDITIONAL BURDENS ON GOVERNMENT PROGRAM PARTICIPATION

Question 1: For 2018, 2019, and/or 2020, did any of the providers affiliated with your practice participate in any of the following programs: the Merit-based Incentive Payment System, the Medicaid Promoting Interoperability program, or any other physician payment program that relied upon a certified EHR and/or quality reporting?

Question 1.a.: If you answered yes, provide the name and NPI of each provider participating in each program, and identify the state that issued the medical license for each provider.

Provider Name NPI State That Issued the Provider’s Medical License

Question 2: Do you claim that issues with the dashboard and/or EHR on Greenway’s software caused providers, employees, or hired third-parties paid by the practice to devote additional hours to participation in a government program in 2018, 2019, or 2020?

IV. CLAIMS FOR LOST MEDICAID PROMOTING INTEROPERABILITY PAYMENTS

Question 1: For each provider for whom you claim a lost Medicaid Promoting Interoperability Program incentive payment, how many Medicaid incentive payments did the provider receive before the year of the claimed lost payment?

Provider Name Number of Payments Received Prior to Year of Lost Payment (0 – 6)

Question 1.a.: Does each provider contend he/she was unable to reasonably attest for 2018, 2019, or 2020 as a result of issues with the dashboard and/or EHR on Greenway's software?

Question 1.b.: Did each of the eligible providers have a Medicaid patient volume of at least 30 percent in the at-issue year(s)?

Question 1.b.1.: If yes, please upload documentation substantiating each provider’s Medicaid volume for the year of the claimed lost payment. Typically, the volume reports submitted for the program should suffice.

Question 2: For each provider for whom you claim a lost Medicaid Promoting Interoperability Program payment, submit a document tending to show likelihood of success of the application. Any of the following would suffice:

  1. A copy of an email or letter from the Medicaid program confirming acceptance of a prior Meaningful Use application by the provider or payment to the provider for 2015, 2016, or 2017, or another record confirming disbursement of the payment for the provider (such as a receipt or copy of a check, printout from your state’s EHR Incentive Program portal showing payments, email or other written verification of successful participation).
  2. Screenshots of the Promoting Interoperability measure dashboard from any time after the first 90 days of the reporting period showing that the measures were being met according to information provided by Greenway.
V. CLAIMS FOR MIPS ADJUSTMENTS

Question 1: For each provider for whom you claim a lost positive adjustment for the Merit-Based Incentive Program, does each provider contend he/she was unable to reasonably attest for 2018, 2019, or 2020 as a result of issues with the dashboard and/or EHR on Greenway’s software?

Question 1.a.: For each provider for whom you claim a negative effect, provide a print-out or PDF print-out or Excel file of the MIPS eligibility report for that provider for the at-issue years (2018, 2019, and/or 2020).

VI. CLAIMS FOR DATA RETRIEVAL AND/OR SWITCHING COSTS

Question 1: Did your practice switch EHRs from the at-issue Greenway product?

Question 2: Did Greenway charge your practice for a retrieval of patient data in connection with your practice’s decision to switch EHRs?

Question 3: Were issues with the EHR and/or the dashboard on Greenway’s software a substantial cause in the practice’s decision to switch EHRs?

VII. DOCUMENTATION

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

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    VIII. Verification

    Question 1: Do you certify that the information provided on this claims form is true and correct under penalty of perjury under the laws of the United States of America? (Y/N)

    Your Claim Form has been submitted successfully.

    HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and log back in to your existing Claim online to re-upload your document(s). Alternatively, you can send your documents with your Submitted Claim ID to the Settlement Administrator by email to: Info@EHRsettlement.com.

    Please print this page for your records.

    Your Claim Details

    Submitted Claim ID:
    Confirmation Code:
    You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
    CLAIM INFORMATION
    Full Name
    Email Address
    Telephone Number
    Street Address
    City
    State
    Zip Code
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@EHRsettlement.com

    Click here to edit your Claim.