Requirements to Receive Wrap-Around (Supplemental) Payments from Medicare
Submitting MA Payment Documentation
- If not previously submitted, the Federally Qualified Health Center (FQHC) must submit the original written contract with the Medicare Advantage (MA) plan that contains the terms specified by 42 CFR 422.527, along with any addendum related to the year under review. These documents must:
- Be signed by both the FQHC and the MA plan.
- A contract with an individual physician doesn't qualify for the supplemental payment.
- The person signing for the FQHC must be a representative of the FQHC.
- Include contract date(s) and effective date(s).
- Include a valid MA contractor number with each contract. If not provided, that contract won't be set up for the supplemental payment. To obtain the MA contractor number, the FQHC should contact the MA plan manager.
- Be signed by both the FQHC and the MA plan.
- The FQHC must provide a detailed listing of claims paid for the previous period by MA contract. Use the FQHC MA Claim Listing Form
or submit a report from the provider's system that must include: - All claims paid by the MA contractor for a period related to the request date. For example, if requesting at the first of the calendar year, the claims listing should include claims from the first of the previous calendar year.
- Alternative report must include:
- Service Date
- Claim Date
- Payment Date
- CPT
- Units
- Billed Fee
- Allowed
- Cost sharing amount charged
- Paid
- Medicare Advantage Plan
- MA Plan Number
- The FQHC must submit the Medicare Advantage plan remittance advices / explanation of benefits for the claims included on the listing from #2 above.
- Send the documentation listed above to J15.REIMBURSEMENT@cgsadmin.com. Properly identify all providers, including those consolidated, that are to receive supplemental payments.
- Submissions must be requested for each contract period or calendar year due to annual updates to FQHC Prospective Payment System (PPS) base payments and MA contract payments. Wrap-around (supplemental) payments won't automatically renew upon contract period or calendar year end.
- Failure to submit a complete list of all MA contracts and identify each consolidated provider with a group of providers could significantly delay wrap payments or cause claim denials.
Submitting Claims
Always follow the instructions in the Medicare Claims Processing Manual (Pub. 100-04), Chapter 9, section 60.4
.
In summary:
- Supplemental payments apply only to qualifying FQHC services furnished during a face-to-face encounter with covered core practitioners:
- Physician
- Nurse Practitioner (NP) / Physician Assistant (PA)
- Certified Nurse Midwife (CNM)
- Clinical Psychologist
- Clinical Social Worker
- Certified Diabetes Self-Management Training (DSMT) / Medical Nutrition Therapy (MNT) provider
- Claim submission requirements:
- Bill Type 77X [don't use 770]
- Revenue Code 0519
- Qualifying visit information
- Supplemental payment made directly by Medicare Administrative Contractor (MAC)
- Don't bill revenue codes 052X or 0900 on the same claim as 0519.
- For PPS supplemental claims, report:
- Revenue Code 0519
- FQHC payment code (G0466-G0470 as applicable)
- Corresponding qualifying visit HCPCS code
- Example: 0519/G0467 and qualifying visit 99213
- Key calculation concepts:
- Medicare deductible isn't applied.
- Original Medicare 20% coinsurance adjustment isn't applied.
- MA beneficiary cost sharing is reflected through MA methodology.
- PPS rate is compared to MA contract rate. If PPS rate is higher, Medicare will pay the difference less sequestration.
Claim Issues
The top 5 errors for MA wrap claims include:
- Revenue code 0519 not used.
- Revenue code 0519 billed on the same claim with 052X or 0900.
- Missing G0466-G0470 payment code.
- Missing qualifying visit HCPCS code.
- Beneficiary not enrolled in MA on the date of service.
Updated: 11.05.2026
Join Electronic Mailing List
Print
Bookmark
Facebook
YouTube
LinkedIn
CGS Medicare Mobile App