The denial-by-denial list we work from, with the state documents that define each rule.
Under managed care the plan pays its contract rate and the state owes the difference up to PPS [1]; CMS noted in 2016 that this produced reconciliation disputes [1].
Trigger line
PPS minus plan
Payer of record
Visit template
Rate reset
Illustrative only; your mix comes from the variance file. The method is in our wrap payment reconciliation worksheet.
| Defect | What the remit shows | Fix |
|---|---|---|
| T1015 billed without a valid encounter code | Whole visit denied or paid at fee schedule | Encounter code required field in the claim scrubber, mapped to the state's valid list |
| Encounter code billed without T1015 or the trigger line | Fee-for-service payment on one line, no PPS | Charge router adds the trigger line on every qualifying visit |
| Non-qualifying practitioner on the encounter line | Denied as not a covered FQHC visit | Rendering provider edit against the state's qualifying practitioner list |
| Second encounter same day, same service type | Duplicate denial | Service-type logic: Maryland allows one somatic, one mental health, one SUD and one dental per day [2] |
Not today
Start and end
Behavioral, dental
T1015 on MSP
State expectations: FQHC payer matrix. On an alternative payment methodology: FQHC APM versus PPS decision guide.
| Denial pattern | Root cause | Fix this week | Fix for good |
|---|---|---|---|
| Wrap missing, MCO paid $0 | Trigger line rejected | Appeal the encounter to the plan with the state's encounter rule attached | Scrubber edit on trigger line and encounter code |
| Wrap short, MCO paid fee schedule | Payment posted to account, not encounter | Recompute PPS minus MCO per visit | Encounter-level posting and variance file |
| Wrap denied, member not enrolled | Retro eligibility change | Re-run eligibility as of DOS, rebill payer of record | Eligibility re-check on every open wrap row |
| Wrap paid at the wrong amount | Prior rate year applied | File the variance by rate year | Rate year on every encounter; calendar the resets |
| Duplicate encounter denial | Same-day service-type rule | Split or combine per the state manual | Service-type templates |
Fix the cause and the wrap pays itself. Appeal the wrap without fixing the cause and the same denial comes back next quarter.
When a Medicaid managed care plan pays an FQHC less than its PPS rate for a qualifying visit, the state owes a supplemental payment equal to the difference. CMS's State Health Official letter of April 26, 2016 describes this requirement under section 1902(bb)(5) and says its purpose is to ensure FQHCs continue to receive their full PPS rate regardless of the delivery system.
Because the wrap is reconciled against the encounter the state can see, not the payment you received. If the encounter line was missing, the MCO rejected it, the member was attributed to a different plan on the date of service, or the rate year is wrong, the state has nothing to reconcile and the wrap is never paid.
No. Maryland requires MCOs to pay the full all-inclusive cost-per-visit rate on the trigger code claim and reconciles with the plans afterward, so the center is not waiting on a wrap. Other states settle claim by claim or by quarterly reconciliation. Read your state's FQHC manual and plan contract before you decide which fix applies.
That depends on the state's reconciliation and timely filing rules, which differ. Keep every encounter keyed to its rate year so late settlements and retroactive rate changes land against the right entitlement, and check the lookback window in your state's FQHC handbook before you file.
Illustrative only; your mix comes from the variance file. The method is in our wrap payment reconciliation worksheet.
Send us a sample of denied wrap encounters and the plan remits. We trace each one to its cause and return the fix list with the state rule attached.