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									                                                                                                                                             CHAPTER

                                       HHSC UNIFORM MANAGED CARE MANUAL                                                                                  5.3.6.1
                                                                                                                                             EFFECTIVE DATE

                                                                                                                                               September 25, 2009
                                                                 FQHC Template
                                                                                                                                                   Version 1.2


                                               DOCUMENT HISTORY LOG
                    DOCUMENT                  EFFECTIVE
    STATUS1                                                         DESCRIPTION3
                    REVISION2                   DATE
                                                               Initial version Uniform Managed Care Manual Chapter
Baseline                    1.0              November 15, 2005
                                                               5.3.6.1 FQHC Report Template
                                                               Chapter 5.3.6.1 is modified to provide clarification
Revision                    1.1              September 1, 2006 resulting from the implementation of the Joint
                                                               Medicaid/CHIP HMO Contract.
                                                               Modified detail report to include columns for Encounter
                                                               Procedure Code, Procedure Modifiers, Other Insurance
Revision                    1.2             September 25, 2009 Payments, and a place to identify contracted providers.
                                                               Removed tab for capitated payments. Modified summary
                                                               report.


1
  Status should be represented as “Baseline” for initial issuances, “Revision” for changes to the Baseline version, and “Cancellation” for
withdrawn versions
2
  Revisions should be numbered in accordance according to the version of the issuance and sequential numbering of the revision—e.g.,
“1.2” refers to the first version of the document and the second revision.
3
    Brief description of the changes to the document made in the revision.
                                                            Federally Qualified Health Center
                                                    Monthly Encounters & Payments Summary Report

FQHC Provider Name:                (1)
FQHC TPI No:                       (2)
MCO Name:                          (3)
Reporting Period:                  (4)                                                                                                     HHSC Signature/Date



                                                                                        VISITS                                                 PAYMENTS
GENERAL MEDICAL
Capitation                                                                                                                                           (5)
MCO FFS Payments                                                                          (6)                                                        (6)
Other Payments                                                                                                                                       (7)
                                                         Total                            (8)                                                        (8)
TEXAS HEALTH STEPS
Capitation                                                                                                                                           (9)
MCO FFS Payments                                                                         ( 10 )                                                     ( 10 )
Other Payments                                                                                                                                      ( 11 )
                                                         Total                           ( 12 )                                                     ( 12 )
FAMILY PLANNING
Capitation                                                                                                                                          ( 13 )
MCO FFS Payments                                                                         ( 14 )                                                     ( 14 )
Other Payments                                                                                                                                      ( 15 )
                                                         Total                           ( 16 )                                                     ( 16 )
VISION
Capitation                                                                                                                                          ( 17 )
MCO FFS Payments                                                                         ( 18 )                                                     ( 18 )
Other Payments                                                                                                                                      ( 19 )
                                                         Total                           ( 20 )                                                     ( 20 )
BEHAVIORAL HEALTH
Capitation                                                                                                                                          ( 21 )
MCO FFS Payments                                                                         ( 22 )                                                     ( 22 )
Other Payments                                                                                                                                      ( 23 )
                                                         Total                           ( 24 )                                                     ( 24 )
CASE MANAGEMENT
Capitation                                                                                                                                          ( 25 )
MCO FFS Payments                                                                         ( 26 )                                                     ( 26 )
Other Payments                                                                                                                                      ( 27 )
                                                         Total                           ( 28 )                                                     ( 28 )


                                   GRAND TOTALS                                          ( 29 )                                                     ( 29 )

We hereby attest to the best of our knowledge to the information on this report is true, accurate and complete and are in compliance with Subpart H of the Balanced
Budget Act Certification requirements; are complete, accurate, and truthful; and in accordance with all Federal and State laws, regulations, policies, and the
HHSC/Contractor contract now in effect. Contractor further certifies that it will retain and preserve all original documents as required by law, submit all or any
part of the same, or permit access to same for audit purposes, as required by HHSC or any agency of the federal government, or their representative(s).


                                   ( 30 )
MCO Authorizing Official:                   Print Name                                                                                               Title
                                   ( 31 )
                                            Signature                                                                                                Date

                                   ( 32 )
FQHC Authorizing Official:                  Print Name                                                                                               Title
                                   ( 33 )
                                            Signature                                                                                                Date

FQHC Contact Person:               ( 34 )
                                            Print Name                                  Phone #                                                E-Mail Address
     UMCM 5.3.6.1 V1.2                                                       FQHC Summary Report                                                                 Eff 9/1/2009
                                                                        FQHC FFS ENCOUNTERS/PAYMENTS DETAIL REPORT
FQHC Provider Name:                   (1)                                               ( 5 ) Contracted Provider?      o YES          o NO
FQHC TPI #:                           (2)                                               ( 6 ) FQHC NPI #:
MCO Name:                             (3)
Reporting Month/Year:                 (4)

                                                                                                                          Billed       Encounter                                           Other
                                    Date of               Member Type of                                    Diagnosis   Procedure      Procedure   Procedure   Number        MCO        Insurance     Payment
 MCO Claim #     FQHC Claim #       Service   Medicaid ID Birthday Service   Last Name        First Name      Code        Code           Code       Modifier   of Visits   Payments     Payments        Date

     (7)               (8)            (9)       ( 10 )     ( 11 )   ( 12 )     ( 13 )           ( 14 )        ( 15 )      ( 16 )         ( 17 )      ( 18 )     ( 19 )         ( 20 )       ( 21 )     ( 22 )


Total General Medical Visits/Payments:          ( 23 )                                                                                                                   0 $       -    $        -




Total THSteps Visits/Payments:                  ( 24 )                                                                                                                   0 $       -    $        -




Total Family Planning Visits/Payments:          ( 25 )                                                                                                                   0 $       -    $        -




Total Vision Visits/Payments:                   ( 26 )                                                                                                                   0 $       -    $        -




Total Behavioral Health Visits/Payments:        ( 27 )                                                                                                                   0 $       -    $        -




Total Case Management Visits/Payments:          ( 28 )                                                                                                                   0 $       -    $        -

                                                                                                                              ( 29 )      GRAND TOTALS:                  0 $       -    $        -




             UMCM 5.3.6.1 V1.2 Eff 9/1/2009                                                    FQHC Detail Report                                                                       Page 3 of 3

								
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