N.J. Admin. Code § 10:66-4 app B
FQHC Annual Cost Reporting Requirements
The following cost report instructions apply to FQHCs that were Medicaid providers on October 31, 2000, for their fiscal years ending on and after June 30, 2001.
In addition, these cost report instructions are for the third year and thereafter, for FQHCs that become Medicaid providers on and after November 1, 2000. The FQHC's first year as a Medicaid provider may represent less than a full year of operation, but is counted as a full year for cost reporting, and a cost report is due to the Division for this period, ending on December 31 of the initial year.
Federally qualified health centers (FQHCs) shall file the Medicare Cost Report (CMS 222-92 (3/93) and all updates), with the Division of Medical Assistance and Health Services (DMAHS). There are services covered by Medicaid that are not covered by Medicare. The cost information below should be included on the Medicare Cost Report that is submitted to Medicare and to the Division. This information will provide Medicaid with cost detail for the additional Medicaid covered services.
Add the following lines to the FQHC Medicare Cost Report, Worksheet A under the category of Facility Health Care Staff Costs:
| Cost Center | Line Number |
| Obstetrics/Gynecology | 11 |
| Podiatrist | 11.01 |
| Cardiologist | 11.02 |
| Specialty Physician (Specify type) | 11.03 |
| Specialty Nurse Practitioner (Specify type) | 11.04 |
| Nurse Mid-Wife | 11.05 |
Add the following lines added under the category of Costs Other than RHC/FQHC Services:
| Cost Center | Line Number |
| Radiology | 56 |
| Outreach | 56.01 |
| Community Service | 56.02 |
| Patient Transportation | 56.03 |
The above subscripted lines will provide additional detailed data on specific costs. The Medicare Cost Report with subscripted lines should be submitted both in hard copy format and on disk to the Division. In addition, FQHCs are required to submit encounter data on Worksheet 2 of the Medicaid Cost Report appearing in N.J.A.C. 10:66-4 Appendix C and the audited financial statements for the cost reporting period. These items are due to the Division on an annual basis and no later than five months after the close of each FQHC's fiscal year.
N.J. Admin. Code 10:66-4 app B
See: 36 New Jersey Register 324(a), 36 New Jersey Register 2834(a).