Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11025A (04/09)

STATE OF WISCONSIN

WISCONSIN MEDICAID

RURAL HEALTH CLINIC COMMERCIAL INSURANCE-PRIMARY / MEDICAID-SECONDARY ENCOUNTERS SUBMITTED TO MEDICAID HMOs INSTRUCTIONS
Wisconsin Medicaid requires information to enable the programs to certify providers and to authorize and pay for medical services provided to eligible members. 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. Failure to supply the information requested by the form may result in denial of payment for the services. The use of this form is voluntary, but providers must collect and maintain all information on the form in some format if they wish to submit a cost report. INSTRUCTIONS: The Rural Health Clinic Commercial Insurance-Primary/Medicaid-Secondary Encounters Submitted to Medicaid HMOs form is to b e completed by provider-based and independent rural health clinics (RHCs) and submitted to Wisconsin Medicaid along with the following forms, which constitute the annual cost report: Rural Health Clinic Trial Balance of Expenses, Reclassifications, and Adjustments form, F-11023? (for provider-based RHCs only). Rural Health Clinic Statistical Data form, F-11022 (for provider-based and independent RHCs). Rural Health Clinic Settlement Determination form, F-11024 (for provider-based and independent RHCs). Rural Health Clinic Medicaid Encounters Submitted to Medicaid HMOs form, F-11026 (for provider-based and independent RHCs.) This form calculates the reimbursement for commercial insurance-primary/Medicaid-secondary encounters submitted to Medicaid HMOs. Guidelines Use the following guidelines for reporting encounters on the form for commercial health insurance encounters: Include encounters where commercial health insurance has paid less than the Medicaid encounters rate and less than the charge. Exclude encounters where commercial insurance has: Paid an amount greater than the Medicaid encounter rate.* Paid the full amount of the charge.* * It is not necessary to submit a claim to Wisconsin Medicaid or to a Medicaid HMO. Exclude encounters where commercial insurance has not paid any amount for the service, even when the recipient has commercial insurance-primary/Medicaid-secondary coverage. Report these encounters as Medicaid-only encounters on Part C of the Settlement Determination form.