FQHC Medicare Advantage billing requires more than sending one claim to the plan. To collect everything you’re owed, the health center bills the Medicare Advantage (MA) plan at its contracted rate and then captures a supplemental “wraparound” payment from Medicare when that contract rate falls below the center’s adjusted PPS rate. Missing the second step is one of the most common ways FQHC Medicare Advantage billing leaves money behind.
How the supplemental payment works
When an FQHC has a written contract with an MA plan, the plan pays at the contract rate. If that rate is lower than the adjusted PPS rate, Medicare pays the difference — minus any patient cost-sharing — as a supplemental wraparound payment. If the MA contract rate is higher than the PPS rate, no supplemental payment is due.
The two-claim process
Capturing the supplemental payment means submitting two claims for the encounter: one to the MA plan and one to traditional Medicare. The Medicare claim is submitted on Type of Bill (TOB) 77X using revenue code 0519 on the lines to signal the intent to collect the supplemental amount.
- Don’t wait — the supplemental claim can be submitted at the same time as the MA claim, not only after the plan adjudicates.
- Compare rates first — reviewing MA contract rates against adjusted PPS rates shows where the supplemental opportunity is largest.
Across an MA patient panel, these supplemental payments can represent substantial revenue. Yet because FQHC Medicare Advantage billing adds a second claim and a separate reconciliation step, many centers capture the plan payment and quietly forfeit the wraparound. A disciplined process that files both claims and tracks the supplemental ensures the full PPS-equivalent reimbursement actually arrives.
Capturing every Medicare Advantage supplemental payment you’re owed? Squadyen handles the two-claim FQHC Medicare Advantage billing process — request a free review.