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.