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August 7, 2020

MA Supplemental Wrap-Around Payments (reason code 37098)

For claims with the 0519 revenue code, the wraparound payment is based on the PPS (Prospective Payment System) rate without comparison to the provider's charge.  For a FQHC visit, Medicare will compare the PPS (Prospective Payment System) rate with the Medicare Advantage (MA) contract rate.

When the MA 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 applicable PPS rate.

For each MA plan the FQHC has a contract with, the FQHC is required to submit documentation showing an estimate of the average visit payment for the MA enrollees. A cover letter that includes the provider list, contact name and contact signature should be sent along with the supporting documentation listed below. 

Each MA contract should include the following information:

  • Contract Number
  • Provider name
  • MA contract name
  • Contract Dates
  • Effective dates
  • Signature from provider
  • Signature from the MA contract representative

Rate Calculation should include following information:

  • Contract number
  • Procedure codes
  • Units
  • Rates
  • Payment amounts
  • MA payment rate per visit
  • A detailed list of claims that support the rate calculation

Information can be emailed to: J15.Reimbursement@CGSAdmin.com or sent via mail to:  

CGS Administrators, LLC
J15 Part A Audit and Reimbursement
PO Box 20020
Nashville, TN 37202

Please remember that it is the provider's responsibility to their Medicare Advantage Contractor (MAC) updated with all their participating MA plan contracts. Please note that claims will be returned to the provider (RTP) with reason code 37098 when the FQHC PPS supplemental rate is not present for the MA plan. When the Medicare claims processing system is not updated with the MA plan information, the above documentation will be required.

Reference:

  • CMS Medicare Claims Processing Manual (Pub 100-04), Chapter 9:Rural Health Clinics/Federally Qualified Health Centers, Section 60.4: Billing for Supplemental Payments to FQHC's under Contract with Medicare Advantage (MA) Plans

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