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32 <br />9.EHR Vendor Product & Version: <br />10. Hosting Location: <br />……On-site ……Cloud-based  <br />……Hub/server on-site at <br />another location……Other: _____________ <br />11. EHR Vendor Contact Name: <br />12. EHR Vendor Contact Email: <br />13. EHR Vendor Contact Phone Number: <br />State Funding Information <br />14. Do you accept and receive reimbursement <br />from NC Medicaid?…Yes …No <br />15. If yes to 14, do you receive reimbursement <br />through a Managed Care Organization (MCO) <br />or Local Management Entity (LME)? <br />…Yes …No <br />If yes, please specify:_____________________________ <br />16. Do you accept and receive reimbursement <br />from NC State Health Plan?…Yes …No <br />17. Do you receive any other funds from the <br />State of North Carolina for the provision of <br />health services, including grants? <br />…Yes …No <br />HIE Features <br />18. NC HIEA offers Direct Secure Messaging <br />(DSM) at no cost. Would you be interested in <br />learning more about these services? <br />…Yes …No <br />19. Would your organization be interested in <br />connecting to the NC Immunization Registry <br />through NC HealthConnex? <br />…Yes …No <br />Technical Specifications for Onboarding & Targeted Data Standards <br />1.EHR Product.Any ONC certified EHR Product can be connected to NC HealthConnex. Other EHR <br />Products may also be used if the product is capable of sending HL7 messages, version 2 and higher. The <br />timeline for connecting your organization will depend on various factors, including the technical resources <br />and capabilities of your EHR vendor, any work already undertaken by NC HIEA, SAS Institute (“SAS,” <br />our technology partner and subcontractor), and your EHR vendor to connect other participants, and <br />resources available at your organization, NC HIEA, and SAS. <br />2. Targeted Data Standards <br />a.CCD/CCDA Submission and Exchange. Participants with ONC certified EHR Products that <br />are Meaningful Use Stage 2 Certified shall submit the following data elements to NC <br />HealthConnex to the extent possible for all data pertaining to Medicaid, State Health Plan, and <br />State-funded health services provided by Participant as required by Applicable Law. <br />i. Meaningful Use Data Elements within the Clinical Summary or Discharge Summary <br />MU2 Summary Types. The preferred format is XML formatted according to C-CDA r2 <br />specifications. <br />ii. Inbound and Outbound from NC HealthConnex: <br />1. Inbound Feed to NC HealthConnex <br />ESO Suite v5.16.1764.0 <br />Zac Taylor <br />zac.taylor@eso.com <br />9199036252 <br />✔ <br />✔ <br />✔ <br />✔ <br />✔ <br />✔ <br />✔ <br />DocuSign Envelope ID: 47B4445A-C7CA-4D2E-9075-2AFD82F82DEC