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SOUTH CAROLINA DEPARTMENT OF HEALTH &
HUMAN SERVICES
Federally Qualified Health Center
(FQHC)
December 2011
OBJECTIVES
Review policy basics
FQHC Basics & Co-payments
Third Party Liability
Behavioral Health (BH)
NPI
Physician Services/Contract Request
SC DHHS Tools
Our Website
Using your REMIT
Understanding your ECF
What’s New or Forthcoming
Conclusion
FEDERALLY QUALIFIED HEALTH CENTERS
FQHC services are covered when
furnished to clients at the center, in a
skilled nursing facility, or the client’s
place of residence.
Services provided to hospital patients,
including emergency room services, are
not considered FQHC services.
FQHC SERVICES
All encounter codes and ancillary
services must be billed under the FQHC
provider number.
Only one encounter code may be billed
per day, with the exception of the
Psychiatry and Counseling encounter.
FQHC SERVICES CONT’D
All medical encounters must be billed using the
procedure T1015.
Maternal encounters must be billed with the “TH” modifier.
Psychiatric and counseling encounters must be billed with the “HE” modifier.
HIV/AIDS and Cancer related related encounters must be billed with the “P4” modifier.
Family planning services must be billed with the “FP” modifier.
FQHC SERVICES CONT’D
Place of service code for the FQHC will
always be 50
72 Rural Health Clinics
11 Office
21 Inpatient Hospital
22 Outpatient Hospital
FQHC SERVICES CONT’D
All EPSDT screenings must be billed using CPT codes: 99381-99385
99391-99395
Other Special Clinic Services: J7300 Paraguard IUD
J7307 Etonogestrel Implant (Implanon™)
J7302 Levonorgestrel-releasing intrauterine contraceptive (Mirena), 52mg
S4989 Progestasert IUD
J1055 Depo-Provera for family planning
J1950 Leuprolide Acetate, per 3.75mg
59025-TC Non-stress test, technical component
90658, Q2035, Q2036, Q2037, Q2038, Q2039 Influenza vaccine
90732 Pneumococcal vaccine
90378 Respiratory Syncytial Virus, 50mg
SCHEDULE OF CO-PAYMENTS
Type of Services Service
Amount
FQHC T1015 $3.30
Physician Office Visits 90801 $3.30
Physician/Nurse Practitioner 92002-92014
99201-99205
99212-99215
99241-99245
99271-99275
RHC T1015 $3.30
CO-PAYMENTS CONT’D
Pursuant to federal regulations, the following are excluded from co-payments:
Children under age 19
Institutionalized individuals
Home-based and community-based individuals
Individuals receiving hospice care, family planning services, pregnancy-related services, and emergency services
THIRD PARTY LIABILITY (TPL)
“Third-party liability” (TPL) refers to the
responsibility of parties other than Medicaid to pay for health insurance costs. Medicaid is always the payer of last resort, which means that Medicaid will not pay a claim for which someone else may be responsible until the party liable before Medicaid has been billed.
Private health insurers and Medicare are the most common types of third party that providers are required to bill.
THIRD PARTY LIABILITY CONT.
Medicaid Only Encounter Rate
Medicaid/Medicare Encounter Rate – TPL
Payment, Not to exceed
Medicare coinsurance
and deductible amount
Medicaid/Other TPL Encounter Rate – TPL
Payment
BEHAVIORAL HEALTH (BH) – T1015 HE
New policy to be effective February 2012 (available
January 2012)
Twelve (12) annual BH visits allowed
Bill using T1015 HE modifier
Additional visits require prior authorization
Must meet medical necessity criteria
Eligibility for BH requires diagnoses from the
current edition DSM/ICD.
BEHAVIORAL HEALTH (BH) – CONT.
Must have a referral/order from MD/APRN to
initiate BH services.
Medical necessity must be confirmed and
documented annually by an MD, qualified Nurse
Practitioner, LISW or Psychologist.
IPOC required for all clients within 60 calendar
days of medical necessity confirmation.
All services must be documented on CSN
If continued services are needed the MD/APRN
must complete a new referral, at least annually.
NATIONAL PROVIDER IDENTIFIER (NPI)
The NPI is required for all HIPPA Standard
Transactions billed on or after May 23,
2008. This means:
ONLY the NPI will be accepted and sent on all
electronic and paper transactions. SC DHHS
will no longer accept your six character SC
Medicaid legacy number.
The use of the legacy number will result in
rejections.
NPI CONT’D
- Remember………..
ONE NPI for EACH
LOCATION
EACH LOCATION is credentialed
and contracted separately
TAXONOMY CODES
The taxonomy code is a unique 10-digit
specialty code assigned under the HIPPA
provisions to health care provider.
The taxonomy code denotes:
Provider Type
Classification
Area of Specialization
FILING CLAIMS WITH YOUR NPI
A FQHC is NOT a group
The FQHC has ZERO members
The NPI for the rendering and pay-to
provider should always be the same
The taxonomy code is always the same
for the pay-to and rendering provider
FILING CLAIMS WITH YOUR NPI
FILING CLAIMS WITH YOUR NPI
CONTRACT REQUEST
In order for your clinic to be enrolled as a
FQHC, Physician Services will need the
following information:
CMS Certification Letter
Notice of Grant Award(NGA)form Health
Resources and Services
Administration(HRSA)
Written request from the facility
Rate Letter
CONTRACT REQUEST CONT’D
- Once the above information has been gathered by your
organization, the information will need to be faxed to:
FQHC Program Manager/Physician Services @ (803)
255-8255
- SC Medicaid request that your organization return all
requested Contract information at the same time.
- Faxing an incomplete packet to the FQHC Program
Manager, will only slow down your request
SOUTH CAROLINA
DEPARTMENT OF HEALTH & HUMAN
SERVICES
TOOLS
SC DHHS PROVIDER TOOLS
SC Medicaid at your fingertips:
www.scdhhs.gov Provider manual
Current Fee schedule
Managed Care information
Sample REMITTANCE advice
Sample Edit Correction Form
Physician Services Provider Manual: Section 2 – P&P Section 3 – Billing
REMITTANCE ADVICE
The remittance advice (RA) is a
notification of claim status:
Available weekly on Web Tool
Accompanied by Edit Correction Forms (ECF)
Cannot be used to correct an edit
REMITTANCE ADVICE CONT’D
Claim Status Inquiry
After 45 days have elapsed and a new claim
has not appeared in a remittance advice:
Submit a new claim
Claim Status
“P” = Paid Claim
“R” = Rejected claim
“S” = Suspended claim
EDIT CORRECTION FORM
ECF’s are generated when a claim is entirely
rejected (no payment made).
Appropriate documentations or appropriate
corrections must be made to the ECF for
processing.
Do not attach additional ECFs, CMS 1500’s or RA’s as
documentation
Each ECF is processed separately.
Do not send multiple ECFs with one set of
documentation.
CORRECTING THE ECF
The ECF is generated for the purpose of making
corrections to the original claim.
ALL corrections must be made in RED ink.
Check the edit code section of the ECF to
determine the edits.
Edits are assigned to either the entire claim or a
specific line.
Review your edit code list in Appendix 1 of your
provider manual to determine the nature of the
edit and how to correct it.
COMMON EDITS
715 Place of Service/Procedure code inconsistent
932 Pay to provider not group/Line provider not same
911 Individual provider not member of group
989 Recipient in HMO plan
712 Recipient age-procedure code inconsistent
COMMON EDITS: CONT.
965 PCCM Recipient/Rendering provider not
PCP-procedure code requires referral from
PCP
722 Procedure Modifier and specific pricing
not on file
SC DHHS RESOURCES
Provider Call Center
Div of Physician Services
Div of Managed Care
IVRS: Eligibility & TPL
Cost Settlements: Debbie Strait
www.scdhhs.gov
www.scchoices.com
(888) 289-0709
(803) 898-2660
(803) 898-4614
(888) 809-3040
(803) 898-1042
SC DHHS ADDRESSES
CMS 1500 Claims and ECFs
Medicaid Claims Receipt
P O Box 1412
Columbia, SC 29202-1412
Provider Enrollment Forms
Medicaid Provider Enrollment
P O Box 8809
Columbia, SC 29202-8809
Provider Prior Authorizations
must be submitted via facsimile to:
Alliant Health Solutions - (803) 255-8260
WHATS NEW OR FORTHCOMING
All individual providers of service will need to
be enrolled with Medicaid
Billing requirements will be changed to reflect
individual providers information on the claim
PRESENTER
WILLIAM FEAGIN DIRECTOR OF POLICY AND PROGRAM ADMINISTRATION
OFFICE OF PHYSICIANS, PHARMACY, AND MEDICAL SUPPORT SERVICES
803-898-2660
QUESTION’S AND ANSWER'S
Question: Can a FQHC clinic bill for a medical and dental
visit on the same day?
Answer: Yes, as long as the dental provider has been
enrolled and issued a dental provider number (ZA0000)
QUESTION’S AND ANSWER’S CONT’D
Question: How are claims billed to Fee for Service, after
receiving rejection from the Medicaid HMO?
Answer: SC Medicaid will need for you to attach a copy of
your rejection notice from the Medicaid HMO to your
CMS1500 and submit to the Medicaid Claims address
QUESTION’S AND ANSWER’S CONT’D
Question: I only have the FQHC provider number
FQC###. Can you advise me how to file for fee-for-
service? Is there another provider number for these
services? If so, how do I obtain that number?
Answer: As of 05/24/2008 all claims are submitted to SC
Medicaid under the provider NPI Number with the
taxonomy included. An NPI can be obtained and
registered at the following internet address:
https://nppes.cms.hhs.gov/NPPES/Welcome.do
QUESTION’S AND ANSWER’S CONT’D
Question: How does Medicaid want us to handle the
Medicare/Medicaid crossovers due to the fact that SC
Medicaid is unable to accept the automatic crossovers
from Medicare and when will that be resolved?
Answer: SC Medicaid will always be the payer of last
resort when “other” insurance is involved. Crossover
claims from Medicare have not been accepted since
2001. The provider will need to bill the primary
insurance, wait for a response from the primary
insurance, then bill SC Medicaid for a response.
QUESTION’S AND ANSWER’S CONT’D
Question: (Maternity billing) During a SCPHCA meeting,
SC Medicaid Rep advised FQHCs that we could bill
Medicaid directly for maternity services despite TPL. I
understand this to mean, when I bill a maternity T1015-
TH service, I can bill directly to Medicaid, and not bill
the TPL on file. I also would infer that when we bill for
CPT 59409, we could bill this directly to SC Medicaid. If
this is not correct, please explain.
Answer: As stated in April, this is an OPTION. This
information is covered in the TPL Section of the
provider Manual.
QUESTION’S AND ANSWER’S CONT’D
Question: Billing items outside the FQHC umbrella to Medicaid (i.e. Labs performed in-house)
Answer: In the Manual, Supplies, lab work, injections, etc., are not billable services. These services and supply costs are included in the encounter rate when provided in the course of a physician, physician assistant, nurse practitioner, certified nurse midwife, chiropractor, clinical psychologist, and/or clinical social worker visit.
Non-stress tests, EKGs, and x-rays performed in the center must be billed using the appropriate CPT-4 code with a TC modifier indicating the technical component only.