Free F-11027A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11027A (04/09)

STATE OF WISCONSIN

WISCONSIN MEDICAID

RURAL HEALTH CLINIC QUARTERLY COST REPORT 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 Medicaid 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 Quarterly Cost Report form may be completed by provider-based and independent rural health clinics (RHCs) and submitted to Wisconsin Medicaid. Quarterly Cost Report Completion and Deadlines Rural health clinics are responsible for accurate completion and submission of the quarterly RHC cost reports. To receive a quarterly reconciliation payment, submit a quarterly cost report to the following address: Rural Health Clinic Auditor Bureau of Program Integrity Division of Health Care Access and Accountability PO Box 309 Madison WI 53701-0309 For all lines, report encounters with dates of service within the reporting period only. 1. Reporting Period Enter the quarterly reporting period dates. Rural Health Clinic Information List the full name of the clinic, the clinic's address, the RHC billing provider's National Provider Identifier (NPI) or Medicaid provider number, and any non-RHC NPI or Medicaid billing provider numbers held by the clinic or its providers. Contacts a) List the name, title, telephone number, and fax number of the individual who should receive notices of adjustments, settlements, and other correspondence. b) Preparer of Report: List the name, title, telephone number, and fax number of an individual to be contacted if more information or clarification of the report is required. Quarterly Settlement Determination Line 1: Report the encounter rate used on the most recently audited cost report submitted to Wisconsin Medicaid. (Note: Quarterly cost reports can only be submitted after a clinic has operated as an RHC continuously for 12 months.) Line 2: Report Medicaid encounters submitted to Wisconsin Medicaid or Medicaid HMOs for which payments have been received. Lines 4a and 4b: Report Medicaid fee-for-service and Medicaid HMO payments received separately. Line 4c: Report Medicare payments received for Medicare/Medicaid encounters. Line 4d: Report commercial insurance payments. Line 4e: Report total copayments due to the provider from Medicaid members. This amount may be different from the amount actually received by the provider if all copayments have not been paid. Line 5: Represents the quarterly payment due to the provider. Certification by Officer or Administrator of Clinic Enter the name, telephone number, and signature of the individual who prepared this report and who can be contacted if more information or clarification is required. The authorized individual who signs the annual Medicaid RHC cost reports must sign this cost report.

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