Free WISCONSIN MEDICAID DECLARATION OF SKILL ACQUISITION -- PRIVATE DUTY NURSING FOR MEMBERS VENTILATOR DEPENDENT FOR LIFE-SUPPORT AD - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11130A (04/09)

STATE OF WISCONSIN

WISCONSIN MEDICAID

FEDERALLY QUALIFIED HEALTH CENTER INTERIM REPORT COMPLETION INSTRUCTIONS
Wisconsin Medicaid requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Although these form instructions refer to Wisconsin Medicaid, this form also applies to the BadgerCare Plus Standard Plan, the BadgerCare Plus Benchmark Plan, and the BadgerCare Plus Core Plan for Childless Adults. Personally identifiable information about providers is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. The Federally Qualified Health Center Interim Report, F-11130, may be used to submit partial cost report information to Wisconsin Medicaid to receive interim payments and streamline cash flow between annual cost report submissions. Interim reports may be submitted to Wisconsin Medicaid on a quarterly basis, except when a federally qualified health center (FQHC) is granted express permission to submit more frequently. The use of this form is voluntary, but providers are required to submit the information required on the form for a settlement determination and payment to take place. INSTRUCTIONS Wisconsin Medicaid FQHCs interested in receiving a partial cost settlement for services rendered to Wisconsin Medicaid members for a given fiscal year may submit an interim report to Wisconsin Medicaid. Interim reports may be submitted at any time within the current fiscal year for activity occurring within that time period. Providers may submit an interim report by fax to Wisconsin Medicaid at (608) 267-3380 or by mail to the following address: Wisconsin Medicaid Bureau of Program Integrity FQHC Auditor PO Box 309 Madison WI 53701-0309 The FQHC is responsible for assuring that the interim report is signed before it is submitted and that the Wisconsin Medicaid FQHC Auditor receives the interim report after it is submitted. Interim payments made by Wisconsin Medicaid to FQHCs are subject to recoupment if a cost report is not submitted for the fiscal year in question. Interim payments made by Wisconsin Medicaid to FQHCs are also subject to recoupment at the time of annual cost settlement calculation if the sum of payments exceeds the annual cost settlement calculation. Federally qualified health centers are encouraged to make conservative estimates when submitting interim requests.

SECTION I -- PROVIDER INFORMATION Name -- Federally Qualified Health Center (FQHC) Enter the name of the FQHC. Provider Number Enter the FQHC's National Provider Identifier (NPI) or Wisconsin Medicaid provider number.

SECTION II -- DATES FQHC Interim Reporting Period Enter the beginning and ending dates of this interim report respectively in the "From" and "To" portions of this element in MM/DD/YY format. FQHC Fiscal Year End Date Enter the ending date of the FQHC fiscal year to which this interim report pertains.

FEDERALLY QUALIFIED HEALTH CENTER INTERIM REPORT COMPLETION INSTRUCTIONS F-11130A (04/09)

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SECTION III -- ENCOUNTERS AND CHARGES The FQHC is required to separate the information for dates of service occurring in the interim reporting period (Columns A-D) and the fiscal year-to-date (Columns E-H) in this section. The following instructions should be used to report information in both sets of columns. Line 1a -- Professional Encounters Actual Enter the actual number of encounters for non-Medicaid patients (Columns A and E) and members enrolled in Medicaid (Columns B and F). Next, enter the total actual encounters (Columns C and G), and then calculate the percentage of these that are actual Medicaid encounters (Columns D and H). The encounters for members enrolled in Medicaid should be paid encounters or those that the provider reasonably expects to receive payment. Line 1b -- Professional Encounters Budgeted Enter the budgeted number of encounters for non-Medicaid patients (Columns A and E) and members enrolled in Medicaid (Columns B and F). Next, enter the total budgeted encounters (Columns C and G), and then calculate the percentage of these that are budgeted Medicaid encounters (Columns D and H). The encounters for members enrolled in Medicaid should be paid encounters or those that the provider reasonably expects to receive payment. Line 2 -- Charges Enter the charges for non-Medicaid patients (Columns A and E) and members enrolled in Medicaid (Columns B and F). Next, enter the total charges (Columns C and G), and then calculate the percentage of those that are Medicaid charges (Columns D and H).

SECTION IV -- PAYMENTS AND EXPENSES The FQHC is required to complete either the "Actual" or "Budgeted" column for all lines in this section for both the interim reporting period and the fiscal year-to-date. The FQHC should complete the "Actual" column unless the FQHC has experienced changes that have resulted in a significantly different encounter rate than the rate that was established on the most recently audited Medicaid FQHC cost report. In this case, the FQHC should complete the "Budgeted" column for all lines in this section to reflect a more realistic encounter rate. When the "Budgeted" column is used, the FQHC is required to include written justification explaining the changes experienced by the FQHC that make the use of a budgeted encounter rate necessary. Line 3 -- Encounter Rate Enter the encounter rate from the most recently audited Medicaid FQHC cost report, or if significant changes have occurred for the FQHC, a budgeted encounter rate. Line 4 -- 100 Percent of Reasonable Costs -- Preliminary Enter the product of the actual Medicaid encounters from Line 1a, Column B and the encounter rate from Line 3. Lines 5 a-e -- Less Medicaid-Related Amounts Received or Receivable from -- Enter the amounts that the FQHC has received from Medicaid, Medicare, Medicaid HMOs, third party/insurance, and member copayments for services provided. If the figure indicated on Line 1a, Column B includes encounters the provider reasonably expects to be paid for, the figures entered in Lines 5 a-e should contain payments reasonably expected to be received for those encounters. Line 5f -- Total Medicaid Amounts Received or Receivable Enter the sum of lines 5 a-e. Line 6 -- Total Unreimbursed Costs for Period Enter the difference between Line 4 and Line 5f. Line 7 -- Interim Payment Limitation Enter the interim payment limitation to be applied to this interim report, if applicable. An interim payment limitation (e.g., 85 or 90 percent) may be applied to ensure that the FQHC does not receive interim payments that are greater than the amount due upon audit of the annual cost report. An interim payment limitation may be applied in the following circumstances: The FQHC is relatively new and without an established fiscal history and a budgeted cost report has been used to establish a temporary encounter rate. An encounter rate has been assigned to a relatively new FQHC, but lack of fiscal history raises uncertainty whether the encounter rate may result in overpayment to the FQHC. Recent cost report audits have resulted in overpayment to the FQHC. Changes at the FQHC raise uncertainty of whether the audited encounter rate may result in overpayment to the FQHC. The FQHC is reporting a conservative amount due on the interim report. Wisconsin Medicaid reserves the right to impose an interim payment limitation if it is deemed necessary.

FEDERALLY QUALIFIED HEALTH CENTER INTERIM REPORT COMPLETION INSTRUCTIONS F-11130A (04/09)

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Line 8 -- Subtotal Interim Payment to be Made to FQHC Enter the product of Line 6 and Line 7. Line 9 -- Outstationed Enrollment Expenses Enter the amount of outstationed enrollment expenses actually incurred by the FQHC. These expenses may be reimbursed at 100 percent of cost on the interim report. Line 10 -- Total Interim Payment to be Made to FQHC Enter the total of Line 8 and Line 9. This is the total payment to be made to the FQHC for this interim report.

SECTION V -- SIGNATURES SIGNATURE and Title -- Person Preparing Report The person preparing the interim report is required to sign the report and state his or her title. Telephone Number -- Person Preparing Report Enter the telephone number of the person preparing the interim report. Date Signed -- Person Preparing Report Enter the date the person preparing the interim report signed the report. SIGNATURE -- FQHC Officer or Administrator The FQHC Officer or Administrator is required to sign the interim report. Name -- FQHC Officer or Administrator Print the name of the FQHC Officer or Administrator. Date Signed -- FQHC Officer or Administrator Enter the date the FQHC Officer or Administrator signed the interim report.