FQHCs must submit claims for reimbursement on the UB-92 claim
form or its successor. See 8.302.2 NMAC, Billing for Medicaid
Services [MAD-702]. Once enrolled, providers receive instructions on
documentation, billing, and claims processing. Interim reimbursement for
services provided by an FQHC is made by MAD based on submitted claims.
Initial rates: The initial
interim rate for new FQHC providers will be the interim rate set by
(1) FQHCs must submit cost
reports on an annual basis to MAD or its designee within the time frames
specified by medicare. FQHCs will not be granted an extension to the cost
report filing time frames.
final cost settlement based on the audit data will be made in accordance with
delineated medicaid requirements and/or applicable medicare cost reimbursement
principles when medicaid requirements are not specified. Final cost settlements
are based on the allowable cost as audited or desk reviewed costs by MAD or its
designee. "Allowable costs" are costs incurred by an FQHC which are reasonable
in amount, proper and necessary for the efficient delivery of services by the
FQHC (MAD or its designee will follow the HCFA Pub. 15-1 in determining
allowable costs). The supporting documentation for "allowable costs" must be
available upon request from MAD or its designee.
MAD or its designee may reopen cost
reports per HCFA Pub. 15-1 Section 2931 through 2932.1. Providers will be
notified on a case-by-case basis thirty (30) days prior to any reopening. MAD
uses the productivity standards used in the medicare cost report. However, MAD
does not use the costs limits imposed by medicare. If an FQHC disagrees with an
audit settlement, the provider can request a reconsideration. See 8.350.4
Reconsideration of Audit Settlement
(4) HSD or its designee will complete their
initial review of cost settlement materials within 150 days of the receipt of
all required information.
What constitutes a visit:
visit is a face-to-face encounter between a center client
and a physician,
physician assistant, nurse practitioner, nurse midwife, visiting nurse,
qualified clinical psychologist or qualified clinical social worker. Encounters
with more than one health professional and multiple encounters with the same
health professional on the same day and at a single location constitute a
single visit, except when one of the following conditions exist:
(1) after the first encounter, the client
suffers illness or injury requiring additional diagnosis or
dental visit, or medical visit and another health visit (e.g., a face-to-face
encounter between the client
and a clinical psychologist, clinical social
worker, or other health professional for mental health services listed in
Subsection C of 8.310.4.12
NMAC [MAD 713.33].
FQHCs which executed specific agreements with HSD will receive supplemental
payments for services rendered to clients enrolled in managed care in the
manner and amount specified under the terms of that agreement.
Termination or change of
ownership: The human services department (HSD) reserves the right to
withhold payment on all current and pending claims until HSD rights to recoup
all or portions of such payments is determined from final cost reports when a
change of ownership occurs. Payment will not be withheld if HSD is informed in
writing the current (new) owner or the previous owner agrees to be responsible
for any potential recoupment.