New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 66 - INDEPENDENT CLINIC SERVICES
Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC)
Appendix E
Medicaid Managed Care Wraparound Reports
FQHC-2001-07 Worksheet 2--Support Schedule A--Medicaid Managed Care Encounter Detail
Medicaid managed care encounters provided by Federally Qualified Health Center practitioners must be segregated by calendar month of service. The encounters reported on this worksheet shall not include delivery and OB/GYN surgical encounters reported on Worksheet 2--Support Schedules C and E.
COMPLETION INSTRUCTIONS:
Enter the FQHC Name and FQHC provider number.
Enter the service month and service year.
In Columns 1 though 6, enter the name of each HMO with which the FQHC contracts. If the FQHC is under contract with more than six Medicaid/NJ FamilyCare HMOs, additional pages/columns must be included.
Lines 1 through 6 - In a separate column for each HMO, enter in the appropriate service category the number of encounters provided to Medicaid/NJ FamilyCare managed care patients.
Line 7 - Enter the sum of lines 1 through 6.
Lines 10 through 15 - In a separate column for each HMO, enter in the appropriate service category the number of encounters provided to managed care patients.
Line 16 - In a separate column for each HMO, enter the pneumococcal/influenza vaccine injections provided to Medicaid/NJ FamilyCare managed care patients.
Lines 17 through 25 - In a separate column for each HMO enter in the appropriate service category the number of encounters provided to Medicaid/NJ FamilyCare managed care patients.
Line 26 - Enter the sum of lines 10 through 15, and 17 through 25.
Column 7 - Enter the sum of Columns 1 through 6 for each line.
FQHC-2001-07 Worksheet 2--Support Schedule B-Medicaid Managed Care Receipts
Medicaid managed care receipts received by the Federally Qualified Health Center must be segregated by calendar month of service. The receipts reported on this worksheet shall not include delivery and OB/GYN surgical receipts reported on Worksheet 2 - Support Schedules D and F.
COMPLETION INSTRUCTIONS:
Enter the FQHC Name and FQHC provider number.
Enter the service month and service year.
Line 1 - In Columns A through K, enter the name of each HMO with which the FQHC contracts. If the FQHC is under contract with more than ten Medicaid/NJ FamilyCare HMOs, additional pages/columns must be included.
Line 2 - Enter the effective date of the contract with each managed care company entered on line 1.
Lines 3 through 9 - In a separate column for each HMO, enter the receipts received to date for the services provided to Medicaid/NJ FamilyCare beneficiaries for the service month and year.
Line 10 - Enter the total of the amounts entered in lines 3 through 9.
Column F - Enter the sum of Columns A through E for lines 3 through 9.
Column L - Enter the sum of Columns G through K for lines 3 through 9.
Line 11 - Enter the total of the amounts entered in line 10, columns F and L.
Worksheet 2--Support Schedule C--Medicaid Managed Care Delivery Encounters
Medicaid managed care encounters for delivery encounters provided by Federally Qualified Health Center practitioners must be segregated by calendar month of service.
COMPLETION INSTRUCTIONS:
Enter the FQHC Name and FQHC provider number.
Enter the service month and service year.
Line 3: In Columns B through F, enter the name of each HMO with which the FQHC contracts. If the FQHC is under contract with more than five Medicaid/NJ FamilyCare HMOs, additional pages/columns must be included.
Lines 2 - 27, Column A: Enter the delivery procedure code for encounters provided to Medicaid/NJFamilyCare beneficiaries during the service month and year.
Lines 2 - 17, Columns B through F: In a separate column for each HMO, enter all delivery encounters by procedure code provided for the service month and year.
Lines 2 - 27, Column G: Enter the sum of Columns B through F for each line.
Line 28: Enter the sum of Lines 2 through 27 in Columns B through G.
Worksheet 2--Support Schedule D--Medicaid Managed Care Delivery Receipts
Medicaid managed care receipts for delivery encounters provided by Federally Qualified Health Center practitioners must be segregated by calendar month of service.
COMPLETION INSTRUCTIONS:
Enter the FQHC Name and FQHC provider number.
Enter the service month and service year.
Line 3: In Columns B through F, enter the name of each HMO with which the FQHC contracts. If the FQHC is under contract with more than five Medicaid/NJ FamilyCare HMOs, additional pages/columns must be included.
Lines 2 - 27, Column A: Enter the delivery procedure code for which receipts were received for services provided to Medicaid/NJ FamilyCare beneficiaries for the service month and year.
Lines 2 - 17, Columns B through F: In a separate column for each HMO, enter all delivery receipts received for each procedure code for the service month and year.
Lines 2 - 27, Column G: Enter the sum of Columns B through F for each line.
Line 28: Enter the sum of Lines 2 through 27 in Columns B through G.
Worksheet 2--Support Schedule E--Medicaid Managed Care Ob/Gyn Surgical Encounters
Medicaid managed care encounters for Ob/Gyn surgical encounters provided by Federally Qualified Health Center practitioners must be segregated by calendar month of service.
COMPLETION INSTRUCTIONS:
Enter the FQHC Name and FQHC provider number.
Enter the service month and service year.
Line 3: In Columns B through F, enter the name of each HMO with which the FQHC contracts. If the FQHC is under contract with more than five Medicaid/NJ FamilyCare HMOs, additional pages/columns must be included.
Lines 2 - 27, Column A: Enter the Ob/Gyn surgical procedure code for encounters provided during the service month and year.
Lines 2 - 17, Columns B through F: In a separate column for each HMO, enter all Ob/Gyn surgical encounters by procedure code provided to Medicaid/NJFamilyCare beneficiaries during the service month and year.
Lines 2 - 27, Column G: Enter the sum of Columns B through F for each line.
Line 28: Enter the sum of Lines 2 through 27 in Columns B through G.
Worksheet 2--Support Schedule F--Medicaid Managed Care Ob/Gyn Surgical Receipts
Medicaid managed care receipts for Ob/Gyn surgical encounters provided by Federally Qualified Health Center practitioners must be segregated by calendar month of service.
COMPLETION INSTRUCTIONS:
Enter the FQHC Name and FQHC provider number.
Enter the service month and service year.
Line 3: In Columns B through F, enter the name of each HMO with which the FQHC contracts. If the FQHC is under contract with more than five Medicaid/NJ FamilyCare HMOs, additional pages/columns must be included.
Lines 2 - 27, Column A: Enter the Ob/Gyn surgical procedure code for receipts received for services provided to Medicaid/NJ FamilyCare beneficiaries during the service month and year.
Lines 2 - 17, Columns B through F: In a separate column for each HMO, enter all Ob/Gyn surgical receipts received for each procedure code for the service month and year.
Lines 2 - 27, Column G: Enter the sum of Columns B through F for each line.
Line 28: Enter the sum of Lines 2 through 27 in Columns B through G.
