Medicare Advantage Wrap-Around Payment

For claims with the 0519 revenue code, the "wraparound," or Medicare Advantage (MA) supplemental payment is based on the PPS rate without comparison to the provider's charge. For a FQHC visit, Medicare will compare the PPS rate with the MA contract rate.

When the MA contract rate is lower than the PPS rate, the contractor will pay the difference, minus any cost sharing amount owed by the beneficiary, as a supplemental wraparound payment. The FQHC does not qualify for a supplemental wraparound payment when the MA contract rate is higher than the PPS rate.

MA Contract Submission to Noridian

For each MA plan FQHCs contract with, they are required to submit a documented estimate of their average visit payment for their MA enrollees.

Cover Letter

  • Provider list
  • Contact name
  • Signed cover letter by contact

MA Contract

  • Contract number
  • Provider name and MA contract name, as written in contract
  • Contract dates
  • Effective dates
  • Signature from provider
  • Signature from MA contract

Rate Calculation

  • Contract number
  • Procedure codes
  • Units
  • Rates
  • Payment amounts
  • MA payment rate per visit

Detailed Claim List

  • A list of detailed claims that support information from rate calculation documented supplied

Resource(s)

 

Last Updated Apr 05, 2018