New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) › Appendix E

Current through Register Vol. 56, No. 14, July 15, 2024
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.
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