Instructions for Form DHCS3100 "Federally Qualified Health Center/Rural Health Clinic Managed Care Differential Rate Request Form" - California

ADVERTISEMENT
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
Federally Qualified Health Center/Rural Health Clinic
Managed Care Differential Rate Request Form
INSTRUCTIONS
The Managed Care Differential Rate Request form is designed to comply with Federal and State
regulations to establish a differential rate that reimburses a provider for the difference between their
Prospective Payment System (PPS) rate and their Medi-Cal Managed Care reimbursement. The
information provided on these forms is subject to the Medicare Reasonable Cost Principles in 42 CFR,
Part 413 in accordance with the State’s FQHC/RHC State Plan Amendment.
These forms must be complete and legible; incomplete forms will be returned for correction. If the forms
are returned, instructions will be given noting the deficiencies and corrective action needed.
Submit electronically to
clinics@dhcs.ca.gov
and send hard copies to:
Department of Health Care Services
Financial Audits Branch
Audit Review and Analysis Section
1500 Capital Avenue – MS 2109
P.O. Box 997413
Sacramento, CA 95899-7413
For assistance completing these forms, contact Audit Review and Analysis Section at (916) 650-6696.
MANAGED CARE DIFFERENTIAL RATE PROCESS
If your clinic participates in the Medi-Cal Managed Care program you should complete this form which
provides information on your Managed Care Plan visits and payments. The Department of Health Care
Services (DHCS) uses this information to establish your Code 18 differential rate. The purpose of the
differential rate is to reimburse FQHC/RHC providers on an interim basis the estimated amount payable
for Medi-Cal Managed Care visits.
Once the differential rate is established you may bill the Medi-Cal fiscal intermediary using Code 18 for
each Medi-Cal Managed Care service that meets the definition of a Medi-Cal visit. Also bill the Fee-for-
Service Medi-Cal Managed Care Plan for the patient’s visit as well as the Medicare fiscal intermediary if
dually eligible. At the end of the clinic’s fiscal year, DHCS will determine total payments received from the
Managed Care Plans, Medicare payments (for Managed Care crossover visits), and the Code 18
payments in order to reconcile these against the clinic’s PPS rate. End of year reconciliations are
designed to complete the payment cycle and ensure full PPS rate reimbursement for the applicable visits.
DOCUMENTATION
The reported data on this form is subject to field review by DHCS and must be supported by documentation
such as remittance advice notices, explanation of benefits, or any other documentation that supports the
reported data.
Page 1 of 2
DHCS 3100i (04/11)
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
Federally Qualified Health Center/Rural Health Clinic
Managed Care Differential Rate Request Form
INSTRUCTIONS
The Managed Care Differential Rate Request form is designed to comply with Federal and State
regulations to establish a differential rate that reimburses a provider for the difference between their
Prospective Payment System (PPS) rate and their Medi-Cal Managed Care reimbursement. The
information provided on these forms is subject to the Medicare Reasonable Cost Principles in 42 CFR,
Part 413 in accordance with the State’s FQHC/RHC State Plan Amendment.
These forms must be complete and legible; incomplete forms will be returned for correction. If the forms
are returned, instructions will be given noting the deficiencies and corrective action needed.
Submit electronically to
clinics@dhcs.ca.gov
and send hard copies to:
Department of Health Care Services
Financial Audits Branch
Audit Review and Analysis Section
1500 Capital Avenue – MS 2109
P.O. Box 997413
Sacramento, CA 95899-7413
For assistance completing these forms, contact Audit Review and Analysis Section at (916) 650-6696.
MANAGED CARE DIFFERENTIAL RATE PROCESS
If your clinic participates in the Medi-Cal Managed Care program you should complete this form which
provides information on your Managed Care Plan visits and payments. The Department of Health Care
Services (DHCS) uses this information to establish your Code 18 differential rate. The purpose of the
differential rate is to reimburse FQHC/RHC providers on an interim basis the estimated amount payable
for Medi-Cal Managed Care visits.
Once the differential rate is established you may bill the Medi-Cal fiscal intermediary using Code 18 for
each Medi-Cal Managed Care service that meets the definition of a Medi-Cal visit. Also bill the Fee-for-
Service Medi-Cal Managed Care Plan for the patient’s visit as well as the Medicare fiscal intermediary if
dually eligible. At the end of the clinic’s fiscal year, DHCS will determine total payments received from the
Managed Care Plans, Medicare payments (for Managed Care crossover visits), and the Code 18
payments in order to reconcile these against the clinic’s PPS rate. End of year reconciliations are
designed to complete the payment cycle and ensure full PPS rate reimbursement for the applicable visits.
DOCUMENTATION
The reported data on this form is subject to field review by DHCS and must be supported by documentation
such as remittance advice notices, explanation of benefits, or any other documentation that supports the
reported data.
Page 1 of 2
DHCS 3100i (04/11)
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
STATISTICAL DATA AND CERTIFICATION STATEMENT
Complete Part A, lines 1 through 7 with the requested information. If you need additional space to identify
entities related either through ownership or by control, please attach additional pages with the name, location,
and provider number(s) if applicable. Complete Part B, Certification Statement with the requested information.
The individual signing this statement must be an officer or other authorized responsible person. An original
signature is required.
DIFFERENTIAL RATE FORM
Enter the Clinic Name, Provider Numbers: Legacy and/or National Provider Identifier (NPI), and Fiscal Period.
1. Enter the Medi-Cal Managed Care Plan name(s) under Plan A – I as necessary.
2. Payment Information – check the appropriate box for actual or projected payments.
• A. Enter the Managed Care Plan payments for Medi-Cal beneficiaries from each plan.
• B. Enter the Medicare payments for Managed Care Plan crossover visits for each plan.
• Total Managed Care Plan payments – Add payments from A and B.
3. Visit Information – check the appropriate box for actual or projected visits.
• A. Enter the Managed Care Plan visits for Medi-Cal beneficiaries.
• B. Enter the Managed Care Plan crossover visits for dual eligibles.
• Total Managed Care Plan visits – Add visits from A and B.
PLEASE NOTE - RECONCILING CODE 18:
You must bill the fiscal intermediary for the Medi-Cal Managed Care visits throughout the year if
you want the visits to be reconciled at the end of your clinic’s fiscal year. DHCS will not be able to
reconcile Medi-Cal Managed Care visits that have not been billed to the Medi-Cal program.
Billing Code 18 is not mandatory. If you choose not to bill the Code 18 visits DHCS will assume the
provider has elected to be ‘at risk’ for their Medi-Cal Managed Care Plan services.
Page 2 of 2
DHCS 3100i (04/11)
ADVERTISEMENT

Download Instructions for Form DHCS3100 "Federally Qualified Health Center/Rural Health Clinic Managed Care Differential Rate Request Form" - California

365 times
Rate
(4.6 / 5) 22 votes
Page of 2