REMITTANCE ADVICE AND CAPITATION LISTS Sample Clauses

REMITTANCE ADVICE AND CAPITATION LISTS. The Contractor shall provide Federally Qualified Health Centers (FQHCs) with the option to receive their remittance advices and capitation lists electronically. Regardless of the option chosen by the FQHC, the Contractor shall provide: • Table 18A, FQHC Payments • Table 18B, FQHC Encounters • Table 18C, FQHC Managed Care Wraparound Claim Detail • Table 18D-1, FQHC Managed Care Wraparound Revenue Detail • Table 18D-2, FQHC Managed Care Capitation Roster File Specifications to the DMAHS by the 45th day after the close of the calendar quarter for all claims processed and payments made to the FQHCs for the calendar quarter. Each report should be prepared in a comma delimited ASCII (text) data format or other format approved by DMAHS. The Contractor shall produce reports according to the specifications in Appendix A.7.20 for Tables 18A, 18B, 18C and 18D and in accordance with the timeframes outlined in this contract. In the event that an HMO does not provide capitation payments to an FQHC, the electronic capitation report is required for each FQHC the HMO contracts with, and the electronic capitation report (Table 18D) should contain the following sentence: “The HMO does not provide capitation payments to INSERT FQHC NAME and FQHC FEDERAL TAX INDENTIFICATION NUMBER.” The Contractor must include all payments made to or from an FQHC such as incentive payments, settlements, recoveries, case management fees or any other payments on Table 18D. Fee-For-Service payments must be reported on Table 18C. The required data elements for Table 18C are as follows: Table 18C, FQHC Managed Care Wraparound Claim Detail • Quarter • FQHC Federal Taxpayer Identification Number (TIN) • Facility Name (identify by FQHC servicing site) • Medicaid Provider Number (servicing site) • Clinical Practitioner National Provider Identifier (NPI) • HMO Name • Patient Last Name • Patient First Name • Patient Medicaid Assigned ID • Patient HMO Assigned ID • Patient Social Security Number • Patient Birth Date • Patient Gender Code • Patient Account Number • HMO-assigned ICN • Service Date • HMO Encounter Code • Taxonomy Code • Procedure Code • Procedure Code Modifier 1 • Procedure Code Modifier 2 • Encounter Code • Encounter Code Modifier • Diagnosis Codes (up to 3 codes) • Units of Service • Charge Amount • HMO Paid Amount • Service Category • HMO Payment Category (capitation, fee-for-service) • Check Date • HMO Claim Disposition • Fatal Error Code The required data elements for Table 18D are as f...

REMITTANCE ADVICE AND CAPITATION LISTS. The contractor shall provide federally qualified health centers with electronic remittance advices and electronic capitation lists of enrollees. In addition, the contractor shall provide copies of or a report of the data elements of the electronic remittance advices and capitation lists in Excel format to the DMAHS.