FQHC AND RHC PAYMENT PROCESS CHANGE
Effective 04/01/2015, AHCCCS and its contracted Managed Care Organizations (MCOs) began paying the all-inclusive per visit PPS rate on a per claim basis, replacing the previous 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 did 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 the email FFSRates@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 required all existing AHCCCS-registered 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 with dates of service on and after 04/01/2015. Effective 04/01/2015, new FQHCs, FQHC-LAs, and RHCs will be registered using the new provider types.
A new NPI can be obtained here: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
For questions related to provider registration, please contact Provider Registration at firstname.lastname@example.org.
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.
Services “Incident To” Defined
Services “incident to” a visit means: (a) Services and supplies that are an integral, though incidental, part of the physician’s or practitioner's professional service (examples: medical supplies; venipuncture; assistance by auxiliary personnel such as a nurse or medical assistant); or (b) Diagnostic or therapeutic ancillary services provided on an outpatient basis as an adjunct to basic medical or surgical services (examples: x-ray; medication; laboratory test).
AHCCCS as Secondary Billing
The AHCCCS as secondary payment procedure has not changed for the new FQHC/RHC payment process. The lesser of logic applies, but compared to MCO payment at the PPS rate. Any visits that are reimbursed at a rate other than the PPS rate in this scenario will be accounted for in the Quarterly Supplemental payments and/or the Annual Reconciliation.
FQHC/RHC Billing and Procedure Codes
Effective with dates of service on and after 04/01/2015, all FQHC, FQHC-LA, and RHC visits must be billed using the Form 1500 or the ADA form. For purposes of reimbursing PPS-eligible visits, AHCCCS has adopted HCPCS code T1015 for reporting physical health, behavioral health, and dental visits. This procedure code should be reported on Form 1500 claims and ADA form claims. A claim for an FQHC, FQHC-LA or RHC visit must include all appropriate procedure codes describing the services rendered in addition to visit code T1015.
A visit will be identified by, and reimbursement for the visit will be associated with, HCPCS code T1015; all other services reported on the claim will be bundled into the visit and valued at $0.00.
Further billing instructions are provided in the AHCCCS Fee-For-Service Provider Manual.