5101:3-28-07 Federally qualified health centers (FQHCs): supplemental payments.

(A) Definitions:

(1) "MCP" means a managed care plan, as defined in rule 5101:3-26-01 of the Administrative Code, that reimburses a federally qualified health center(FQHC) for services provided by the FQHC to a medicaid recipient enrolled in the MCP.

(2) "Encounter" is defined in rule 5101:3-28-04 of the Administrative Code.

(3) "Enrollee" otherwise known as a member, means each eligible individual enrolled in an MCP as specified in rule 5101:3-26-01 of the Administrative Code.

(B) Effective for services furnished on or after January 1, 2001, FQHCs that have received payment from an MCP for FQHC services identified in rule 5101:3-28-02 of the Administrative Code are eligible to receive a supplemental payment from the department if the amount the FQHC was paid by an MCP for services provided to an MCP enrollee is less than the amount the FQHC would have received under the prospective payment system(PPS) reimbursement method described in rule 5101:3-28-08 of the Administrative Code.

(C) For services furnished for the period January 1, 2001 to June 30, 2001, FQHCs were eligible to submit quarterly requests for supplemental payments.

(D) Effective for services furnished on and after July 1, 2001 through September 30, 2003, to receive the supplemental payment for an encounter provided to aan MCP enrollee, an FQHC must submit a claim to the department following the Ohio medicaid provider billing instructions utilized by FQHCs for fee-for-service medicaid consumers with third party insurance.

(1) These billing instructions require an FQHC to report the following on the claim:

(a) The encounter code T1015 and the appropriate modifier to signify the type of encounter provided by the FQHC; and,

(b) A detailed CPT code listing reflecting all services provided during the encounter.

(2) FQHCs seeking supplemental payments must also report the following information on the claim:

(a) The third party indicator for the medicaid supplemental payment;

(b) The medicaid provider number of the MCP that paid the FQHC in the referring physician field; and

(c) The sum of the dollar amount the FQHC was paid by any MCP for the service(s) provided to the medicaid recipient listed on the claim minus any incentive payments received from an MCP and any amount received by the FQHC from any other third party insurance.

(E) For services provided on or after October 1, 2003, to receive the supplemental payment, an FQHC must bill for services as outlined in rule 5101: 3-28-11 of the Administrative Code. The data elements submitted for a supplemental payment claim are dependent on whether the claim is a paper claim or an electronic transaction:

(1) If the FQHC chooses to submit a paper claim, submit the data elements outlined in paragraph (D) of this rule except instead of billing the codes to signify the type of encounter, follow the instructions in rule 5101:3-28-11 of the Administrative Code.

(2) If the FQHC chooses to submit an electronic transaction, use the 837 transaction. Report the data elements unique for supplemental claims:

(a) Enter the name of the MCP provider under the "other payer name" field;

(b) Enter the "identification code" of the other payer (the MCP) that initially paid for the services. The identification code is assigned by Ohio medicaid; and

(c) Enter the sum of the dollar amount the FQHC was paid by the MCP for the services without regard to the effects of any financial incentive payments (positive or negative) received from the MCP plus any amount received from any other third party insurance. Enter this amount as the "monetary amount" in the "other payer" area.

(F) Calculation of supplemental payments:

(1) Using the methodology described in paragraph (C) of this rule, the department will pay the FQHC no less frequently than every four months.

(2) For dates of service on and after July 1, 2001, upon receipt of the claim the department will pay any difference between the amount paid by the MCP to the FQHC and the amount due the FQHC based on its PPS rate approved by the department for the specific claim submitted. These payments will occur no less frequently than every four months.

The department's supplemental payment obligation will be determined using the baseline payment that the FQHC would have received under PPS reimbursement as described in rule 5101:3-28-08 of the Administrative Code without regard to the effects of any financial incentives(positive or negative) received from the MCP that are linked to utilization outcomes or other reductions in patient costs.

(G) If a claim is not submitted by an FQHC to the department within the standard time frames required for claims submission in accordance with rule 5101:3-1-19.3 of the Administrative Code, no supplemental payment(s) will be made by the department to the FQHC.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/09/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 8/9/01, 10/1/03