Common use of REMITTANCE ADVICE AND CAPITATION LISTS Clause in Contracts

REMITTANCE ADVICE AND CAPITATION LISTS. The Contractor shall provide Federally Qualified Health Centers (FQHCs) with the option to receive their remittance advices and capitation lists electronically. Regardless of the option chosen by the FQHC, the Contractor shall provide: • Table 18A, FQHC Payments • Table 18B, FQHC Encounters • Table 18C, FQHC Managed Care Wraparound Claim Detail • Table 18D-1, FQHC Managed Care Wraparound Revenue Detail • Table 18D-2, FQHC Managed Care Capitation Roster File Specifications to the DMAHS by the 45th day after the close of the calendar quarter for all claims processed and payments made to the FQHCs for the calendar quarter. Each report should be prepared in a comma delimited ASCII (text) data format or other format approved by DMAHS. The Contractor shall produce reports according to the specifications in Appendix A.7.20 for Tables 18A, 18B, 18C and 18D and in accordance with the timeframes outlined in this contract. In the event that an HMO does not provide capitation payments to an FQHC, the electronic capitation report is required for each FQHC the HMO contracts with, and the electronic capitation report (Table 18D) should contain the following sentence: “The HMO does not provide capitation payments to INSERT FQHC NAME and FQHC FEDERAL TAX INDENTIFICATION NUMBER.” The Contractor must include all payments made to or from an FQHC such as incentive payments, settlements, recoveries, case management fees or any other payments on Table 18D. Fee-For-Service payments must be reported on Table 18C. The required data elements for Table 18C are as follows: Table 18C, FQHC Managed Care Wraparound Claim Detail • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • Facility Name (identify by FQHC servicing site) • Medicaid Provider Number (servicing site) • Clinical Practitioner National Provider Identifier (NPI) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Patient Social Security Number • Patient Birth Date • Patient Gender Code • Patient Account Number • HMO-assigned ICN • Service Date • HMO Encounter Code • Taxonomy Code • Procedure Code • Procedure Code Modifier 1 • Procedure Code Modifier 2 • Encounter Code • Encounter Code Modifier • Diagnosis Codes (up to 3 codes) • Units of Service • Charge Amount • HMO Paid Amount • Service Category • HMO Payment Category (capitation, fee-for-service) • Check Date • HMO Claim Disposition • Fatal Error Code The required data elements for Table 18D are as follows: Table 18D-1, FQHC Managed Care Wraparound Revenue Detail • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • FQHC Name (identify by FQHC servicing site) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Patient Social Security Number • Patient Birth Date • Patient Gender Code • Patient Account Number • Begin Date of Service / Coverage Period • End Date of Service / Coverage Period • Check Date • Check Number • HMO Paid Amount • Payment Category Table 18D-2, FQHC Managed Care Capitation Roster File Specifications • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • Facility Name (identify by FQHC servicing site) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Capitation Month • Check Date • Check Number • Capitation Amount

REMITTANCE ADVICE AND CAPITATION LISTS. The Contractor shall provide Federally Qualified Health Centers (FQHCs) with the option to receive their remittance advices and capitation lists electronically. Regardless of the option chosen by the FQHC, the Contractor shall provide: •  Table 18A, FQHC Payments •  Table 18B, FQHC Encounters •  Table 18C, FQHC Managed Care Wraparound Claim Detail •  Table 18D-1, FQHC Managed Care Wraparound Revenue Detail •  Table 18D-2, FQHC Managed Care Capitation Roster File Specifications to the DMAHS by the 45th day after the close of the calendar quarter for all claims processed and payments made to the FQHCs for the calendar quarter. Each report should be prepared in a comma delimited ASCII (text) data format or other format approved by DMAHS. The Contractor shall produce reports according to the specifications in Appendix A.7.20 for Tables 18A, 18B, 18C and 18D and in accordance with the timeframes outlined in this contract. In the event that an HMO does not provide capitation payments to an FQHC, the electronic capitation report is required for each FQHC the HMO contracts with, and the electronic capitation report (Table 18D) should contain the following sentence: “The HMO does not provide capitation payments to INSERT FQHC NAME and FQHC FEDERAL TAX INDENTIFICATION NUMBER.” The Contractor must include all payments made to or from an FQHC such as incentive payments, settlements, recoveries, case management fees or any other payments on Table 18D. Fee-For-Service payments must be reported on Table 18C. The required data elements for Table 18C are as follows: Table 18C, FQHC Managed Care Wraparound Claim Detail •  Quarter •  FQHC Federal Taxpayer Identification Number (TIN) •  Facility Name (identify by FQHC servicing site) •  Medicaid Provider Number (servicing site) •  Clinical Practitioner National Provider Identifier (NPI) •  HMO Name •  Patient Last Name •  Patient First Name •  Patient Medicaid Assigned ID •  Patient HMO Assigned ID •  Patient Social Security Number •  Patient Birth Date •  Patient Gender Code •  Patient Account Number •  HMO-assigned ICN •  Service Date •  HMO Encounter Code •  Taxonomy Code •  Procedure Code •  Procedure Code Modifier 1 •  Procedure Code Modifier 2 •  Encounter Code •  Encounter Code Modifier •  Diagnosis Codes (up to 3 codes) •  Units of Service •  Charge Amount •  HMO Paid Amount •  Service Category •  HMO Payment Category (capitation, fee-for-service) •  Check Date •  HMO Claim Disposition •  Fatal Error Code The required data elements for Table 18D are as follows: Table 18D-1, FQHC Managed Care Wraparound Revenue Detail •  Quarter •  FQHC Federal Taxpayer Identification Number (TIN) •  FQHC Name (identify by FQHC servicing site) •  HMO Name •  Patient Last Name •  Patient First Name •  Patient Medicaid Assigned ID •  Patient HMO Assigned ID •  Patient Social Security Number •  Patient Birth Date •  Patient Gender Code •  Patient Account Number •  Begin Date of Service / Coverage Period •  End Date of Service / Coverage Period •  Check Date •  Check Number •  HMO Paid Amount •  Payment Category Table 18D-2, FQHC Managed Care Capitation Roster File Specifications •  Quarter •  FQHC Federal Taxpayer Identification Number (TIN) •  Facility Name (identify by FQHC servicing site) •  HMO Name •  Patient Last Name •  Patient First Name •  Patient Medicaid Assigned ID •  Patient HMO Assigned ID •  Capitation Month •  Check Date •  Check Number •  Capitation Amount

REMITTANCE ADVICE AND CAPITATION LISTS. The Contractor shall provide Federally Qualified Health Centers (FQHCs) with the option to receive their remittance advices and capitation lists electronically. Regardless of the option chosen by the FQHC, the Contractor shall provide: • Table 18A, FQHC Payments • Table 18B, FQHC Encounters • Table 18C, FQHC Managed Care Wraparound Claim Detail • Table 18D-1, FQHC Managed Care Wraparound Revenue Detail • Table 18D-2, FQHC Managed Care Capitation Roster File Specifications to the DMAHS by the 45th day after the close of the calendar quarter for all claims processed and payments made to the FQHCs for the calendar quarter. Each report should be prepared in a comma delimited ASCII (text) data format or other format approved by DMAHS. The Contractor shall produce reports according to the specifications in Appendix A.7.20 for Tables 18A, 18B, 18C and 18D and in accordance with the timeframes outlined in this contract. In the event that an HMO does not provide capitation payments to an FQHC, the electronic capitation report is required for each FQHC the HMO contracts with, and the electronic capitation report (Table 18D) should contain the following sentence: “The HMO does not provide capitation payments to INSERT FQHC NAME and FQHC FEDERAL TAX INDENTIFICATION NUMBER.” The Contractor must include all payments made to or from an FQHC such as incentive payments, settlements, recoveries, case management fees or any other payments on Table 18D. Fee-For-Service payments must be reported on Table 18C. The required data elements for Table 18C are as follows: Table 18C, FQHC Managed Care Wraparound Claim Detail • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • Facility Name (identify by FQHC servicing site) • Medicaid Provider Number (servicing site) • Clinical Practitioner National Provider Identifier (NPI) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Patient Social Security Number • Patient Birth Date • Patient Gender Code • Patient Account Number • HMO-assigned ICN • Service Date • HMO Encounter Code • Taxonomy Code • Procedure Code • Procedure Code Modifier 1 • Procedure Code Modifier 2 • Encounter Code • Encounter Code Modifier • Diagnosis Codes (up to 3 codes, use five-digit codes) • Units of Service • Charge Amount • HMO Paid Amount • Service Category • HMO Payment Category (capitation, fee-for-service) • Check Date • HMO Claim Disposition • Fatal Error Code The required data elements for Table 18D are as follows: Table 18D-1, FQHC Managed Care Wraparound Revenue Detail • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • FQHC Name (identify by FQHC servicing site) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Patient Social Security Number • Patient Birth Date • Patient Gender Code • Patient Account Number • Begin Date of Service / Coverage Period • End Date of Service / Coverage Period • Check Date • Check Number • HMO Paid Amount • Payment Category Table 18D-2, FQHC Managed Care Capitation Roster File Specifications • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • Facility Name (identify by FQHC servicing site) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Capitation Month • Check Date • Check Number • Capitation Amount