FQHC AND RHC PAYMENT PROCESS CHANGE

Effective January 1, 2015, AHCCCS and its contracted Managed Care Organizations (MCOs) will begin paying the all-inclusive per visit PPS rate on a per claim basis, replacing the current method of reimbursing claims by the capped fee-for-service fee schedule and annually reconciling to the PPS rate. The method for calculating the all-inclusive per visit PPS rates will not change.

AHCCCS will continue to perform annual reimbursement reconciliations. Additionally, AHCCCS anticipates that quarterly supplemental payments will continue, though in amounts appropriate to the expectation that the MCOs will, in most cases, be paying the PPS rate. MCOs may continue to establish sub-capitated reimbursement arrangements.

All questions related to FQHC/RHC reimbursements should be directed to Victoria Burns at (602) 417-4049 or by email at Victoria.Burns@azahcccs.gov.

 

Provider Registration for FQHCs, FQHC Look-Alikes, and RHCs

AHCCCS has established a provider type for FQHCs and FQHC Look-Alikes (C2) and a provider type for RHCs (29). AHCCCS is requiring that all FQHCs, FQHC-LAs, and RHCs re-register under the applicable provider types, and obtain a unique NPI, not already associated with another active AHCCCS provider ID, for each clinic covered by the CMS FQHC, FQHC-LA, or RHC designation. The new NPIs will be used for claim submissions beginning with dates of service on and after January 1, 2015. All provider registration forms must be submitted by November 1, 2014.

A new NPI can be obtained here: https://nppes.cms.hhs.gov/NPPES/Welcome.do.

For questions related to provider registration, please contact Veronica Valenzuela at (602) 417-7516 or by email at Veronica.Valenzuela@azahcccs.gov.


FQHC/RHC Visit Defined

A face-to-face encounter with a licensed AHCCCS-registered practitioner during which an AHCCCS-covered ambulatory service is provided when that service is not incident to another service. Multiple encounters with more than one practitioner within the same discipline, i.e., dental, physical, behavioral health, or with the same practitioner and which take place on the same day and at a single location, constitute a single visit unless the patient, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment. In this circumstance, the subsequent encounter is considered a separate visit. A service which is provided incident to another service, whether or not on the same day or at the same location, is considered to be part of the visit and is not reimbursed separately.


FQHC/RHC Billing and Procedure Codes

Beginning 01/01/2015, all FQHC, FQHC-LA, and RHC visits must be billed using the Form 1500 or the ADA form. For purposes of reimbursing visits beginning 01/01/2015, AHCCCS has adopted the five 'G' procedure codes recently established by CMS for medical and behavioral health services. These procedure codes should be reported on Form 1500 claims. Claims submitted on the ADA form for dental services will continue to use CDT codes. Claims must include all appropriate procedure codes describing the services rendered in addition to the visit code. A visit will be identified by, and reimbursement for the visit will be associated with, the 'G' code or the key 'D' code; all other services reported on the claim will be bundled into the visit and valued at $0.00.

The five codes that will identify a visit on Form 1500 are:

  • G0466 FQHC visit, new patient
  • G0467 FQHC visit, established patient
  • G0468 FQHC visit, IPPE or AWV
  • G0469 FQHC visit, mental health, new patient
  • G0470 FQHC visit, mental health, established patient

The five codes that will identify a visit on the ADA form are:

  • D0120 Periodic oral evaluation - established patient
  • D0140 Limited oral evaluation - problem focused
  • D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver
  • D0150 Comprehensive oral evaluation - new or established patient
  • D0180 Comprehensive periodontal evaluation - new or established patient

Further billing instructions will soon be provided in the AHCCCS Fee-For-Service Provider Manual.


 

Recent Communication


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