Free F-11026A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11026A (04/09)

STATE OF WISCONSIN

WISCONSIN MEDICAID

RURAL HEALTH CLINIC MEDICAID-PRIMARY ENCOUNTERS SUBMITTED TO WISCONSIN MEDICAID HMOS COMPLETION INSTRUCTIONS
Wisconsin Medicaid requires information to enable the programs to certify providers and 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. 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 Medicaid Encounters Submitted to Medicaid HMOs form is to be 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 Commercial Insurance-Primary/Medicaid-Secondary Encounters Submitted to Medicaid HMOs, F-11025. This form calculates the reimbursement for Medicaid encounters submitted to Medicaid HMOs.