Medicare Advantage (MA) supplemental wrap-around payments -- reason code 37098
Federally qualified health centers (FQHCs) that have a written contract with an MA organization are paid by the MA plan at the rate specified within their contract. If the MA contract rate is less than the Medicare prospective payment system (PPS) rate, Medicare will pay the difference. This is called a supplemental wrap-around payment. Supplemental payments are calculated by determining the difference between the FQHC all-inclusive cost based per visit rate and the average per visit rate received from the MA payment, less the copay the FQHC charges the MA enrollees. Claims will return to provider with reason code 37098 when the FQHC PPS supplemental rate is not present for the MA plan.
When the Medicare claims processing system is not updated with the MA plan information, the following documentation will be required:
- A copy of the signed MA contract by both parties (the FQHC and the MA).
- A completed calculation rate form which shows the MA’s per-visit encounter payment rate computation (either actual or estimate with justification).
- A twelve-month estimate of claims for the MA contract and the period of time in which you are seeking the wrap-around supplemental payment.
- Send all completed information or questions to:
Please remember that it is the provider’s responsibility to keep us current with all their participating MA plan contracts.
Reference:
- Medicare Claims Processing Manual, Publication 100-04, Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers, Section 60.4 "Billing for Supplemental Payments to FQHCs under Contract with Medicare Advantage (MA) Plans"