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Needy Individual Patient Volume and Practice Predominantly Eligibility

Needy Individual Patient Volume: Eligible Professionals (EPs) that work in an FQHC/RHC may choose one (or more) clinical sites of practice to calculate patient volume (i.e., the calculation does not need to be across all of an EP’s sites of practice).  However, at least one site at which the EP is adopting or meaningfully using certified EHR technology must be included in the patient volume.

  • Patient Volume reporting period: any continuous 90-day period during the prior calendar year.
  • Total encounters (denominator): all encounters that the EP provided during the Patient Volume reporting period.
  • Needy Individual encounters (numerator): all services (in the denominator) provided in a day by a specific provider to a Medicaid-enrolled individual. This includes:
    • Services in which:
      • Medicaid (including the program formerly known as “Healthy Kids Gold” and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost sharing); or
      • CHIP (the separate program formerly known in New Hampshire as “Healthy Kids Silver”) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); or
      • Services were rendered to an individual on a sliding scale; or
      • Services were uncompensated;
    • Encounters where Medicaid paid zero dollars ($0) where Medicare (in the case of patients that are dually eligible for both Medicaid and Medicare) or another third party paid for the encounter; or
    • Encounters provided to Medicaid beneficiaries for which no payments were received; or
    • Medical services provided to Medicaid beneficiaries that were not covered under New Hampshire's Medicaid program.

Examples of encounters that CAN be included are:

  • Claims denied due to service limitation audits;
  • Claims denied due to non-covered services;
  • Claims denied due to timely filing; and
  • Services rendered on Medicaid members that were not billed due to the provider's understanding of Medicaid business rules.

Examples of encounters that CANNOT be included are:

  • Claims denied due to the provider being ineligible for the date of service; and
  • Claims denied due to the member being ineligible for the date of service.

Practice Predominantly Eligibility:  EPs that report Needy Individual patient volume must practice predominantly in an FQHC/RHC.  More than 50 percent of their patient encounters must have occurred at a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) during a six-month period during the prior calendar year.

  • Practice Predominantly reporting period:  any continuous six-month period during the prior calendar year.
  • Total encounters (denominator):  EP’s total encounters during the Practice Predominantly reporting period; must include encounters from all locations at which the EP provided services.
  • FQHC/RHC encounters (numerator):  EP’s encounters at the FQHC/RHC during the Practice Predominantly reporting period.
 
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