FQHC

For claims with the 0519 revenue code, the wraparound payment is based on the PPS rate without comparison to the provider’s charge. 

For an FQHC visit, Medicare will compare the PPS rate with the MA contract rate. The rate is not adjusted for coinsurance or preventive services as the MA plan would have already assessed any applicable coinsurance and related waivers of coinsurance.

When the MA contract rate is lower than the PPS rate, the contractor will pay the difference, minus any cost sharing amount owed by the beneficiary, as a supplemental wraparound payment.

The FQHC does not qualify for a supplemental wraparound payment when the MA contract rate is higher than the PPS rate.

For each MA plan, please submit a documented estimate of the average visit payment for the MA enrollees.

Documentation should include a cover letter with the provider list, as well as a contact name, and should be signed by the contact.

Each MA contract should include the following:

• Contract number;
• Provider name and MA contract name;
• Contract dates;
• Effective dates; and
• Signatures from the provider and the MA contract representative

The rate calculation should include the following:

• Contract number
• Procedure codes 
• Units
• Rates
• Payment amounts
• MA payment rate per visit

A detailed claims list that supports the information in the rate calculation should also be included.

The information can be sent via email to JMReimbursement@palmettogba.com or to the address below:

Provider Reimbursement
AG-330
2300 Springdale Drive, Building One
Camden, SC 29020

Last Reviewed: 09/23/2024

As per the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-02, Chapter 13, Section 40: 'An Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) visit is defined as a medically-necessary, face-to-face (one-on-one) encounter between the patient and a physician, nurse practitioner (NP), physicians assistant (PA), certified nurse midwife (CNM), clinical psychologist (CP), or a clinical social worker (CSW) during which time one or more RHC or FQHC services are rendered.'

Last Reviewed: 09/23/2024