Section. 21Federally Qualified Health Center (FQHC)

Transcription

1 Section 21Federally Qualified Health Center (FQHC) Enrollment Medicaid Managed Care Enrollment Reimbursement Medicare-Medicaid Crossover Claims Pricing Provider Cost Reporting Benefits and Limitations Telemedicine Newborn Eligibility Process for FQHCs Claims Information Claim Filing Resources CPT only copyright 2005 American Medical Association. All rights reserved.

2 Section Enrollment To enroll in the Texas Medicaid Program, a federally qualified health center (FQHC) must be receiving a grant under Section 329, 330, or 340 of the Public Health Service Act or designated by the U.S. Department of Health and Human Services (HHS) to have met the requirements to receive this grant. FQHCs and their satellites are required to enroll in Medicare to be eligible for Medicaid enrollment. The Centers for Medicare & Medicaid Services (CMS) has granted a waiver for the Medicare prerequisite at the time of initial enrollment of FQHC parents and satellites. FQHC look-alikes are not required to enroll in Medicare but may elect to do so to receive reimbursement for crossovers. Refer to: Medicare-Medicaid Crossover Claims Pricing on page A copy of the Public Health Service-issued Notice of Grant Award reflecting the project period and the current budget period must be submitted with the enrollment application. A current notice of grant award must be submitted to TMHP Provider Enrollment annually. FQHCs are required to notify TMHP of all satellite centers that are affiliated with the parent FQHC and their actual physical addresses. All FQHC satellite centers billing Medicaid for FQHC services must also be approved by the Public Health Service. For accounting purposes, centers may elect to enroll the Public Health Service-approved satellites using a Federally Qualified Satellite (FQS) provider identifier that ties back to the parent FQHC provider identifier and tax ID number (TIN). This procedure allows for the parent FQHC to have one provider agreement and one cost report that combines all costs from all approved satellites and the parent FQHC. If an approved satellite chooses to bill the Texas Medicaid Program directly, the center must have a separate provider identifier from the parent FQHC and will be required to file a separate cost report. All providers of laboratory services must comply with Clinical Laboratory Improvement Amendments (CLIA) rules and regulations. Providers not complying with CLIA will not be reimbursed for laboratory services. Refer to: Clinical Laboratory Improvement Amendments (CLIA) on page Provider Enrollment on page 1-2 for more information about enrollment procedures. New FQHCs must file a projected cost report within 90 days of their designation as an FQHC to establish an initial payment rate. The cost report will contain the FQHC's reasonable costs anticipated to be incurred during the FQHC's initial fiscal year. The FQHC must file a cost report within five months of the end of the FQHC's initial fiscal year. The cost settlement must be completed within 11 months of the receipt of a cost report. The cost per visit rate established by the cost settlement process shall be the base rate. Any subsequent increases shall be calculated as provided herein. A new FQHC location established by an existing FQHC participating in the Texas Medicaid Program will receive the same effective rate as the FQHC establishing the new location. An FQHC establishing a new location may request an adjustment to its effective rate as provided herein if its costs have increased as a result of establishing a new location Medicaid Managed Care Enrollment FQHCs may be eligible to enroll in Medicaid Managed Care as primary care providers. An FQHC that wants to enroll in Medicaid Managed Care as a primary care provider or specialty provider must contact the individual Medicaid Managed Care health plans for enrollment information Reimbursement FQHCs are reimbursed provider-specific prospective payment system encounter rates in accordance with Title 1 Texas Administrative Code (TAC) To be reimbursed for case management for children and pregnant women (CPW) an FQHC must be approved by the Department of State Health Services (DSHS), Case Management Branch, as a provider of case management services. The FQHC must bill these services using its FQHC provider identifier and the appropriate procedure code for case management of CPW. Refer to: Prospective Payment Methodology in TAC for more information. Case Management for Children and Pregnant Women (CPW) on page Medicare-Medicaid Crossover Claims Pricing For FQHC Medicare-Medicaid crossover claims, the Texas Medicaid Program pays the difference between the Medicaid encounter rate and any Medicare payment up to a maximum of the Medicaid encounter rate. If the Medicare payment is larger, no payment is made by Medicaid Provider Cost Reporting FQHC providers are required to submit a copy of their Medicare audited cost report with the fiscal year ending on or after January 1 within 15 days of receipt from Medicare. Submit to the following address: Texas Medicaid & Healthcare Partnership Medicaid Audit PO Box Austin, TX Benefits and Limitations Medicaid coverage is limited to services provided by the center that are covered by the Texas Medicaid Program and are reasonable and medically necessary. When furnished to a client of the FQHC, medically necessary services include physician services; physician assistant services (PA); nurse practitioner (NP) services; 21 2 CPT only copyright 2005 American Medical Association. All rights reserved.

3 Federally Qualified Health Center (FQHC) clinical nurse specialist (CNS) services; clinical psychologist services; clinical social worker services; other mental health services; vision care services; services and supplies necessary for services that would be covered otherwise, if furnished by a physician or a physician service; visiting nurse services to a homebound individual, in the case of those FQHCs located in an area with a shortage of home health agencies; and other ambulatory services included in Medicaid such as family planning, Texas Health Steps (THSteps), birthing center, and maternity service clinic (MSC). A visit is a face-to-face encounter between an FQHC client and a physician, physician assistant, nurse practitioner, certified nurse-midwife (CNM), visiting nurse, qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exists: After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment. The FQHC client has a medical visit and an other health visit. A medical visit is a face-to-face encounter between an FQHC client and a physician, physician assistant, nurse practitioner, nurse-midwife, or visiting nurse. An other health visit includes, but is not limited to, a faceto-face encounter between an FQHC client and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a THSteps medical checkup. All services provided that are incident to the encounter should be included in the total charge for the encounter and are not billable as a separate encounter. For example, if an office visit was provided at a charge of $30 and a lab test for $15, the center would bill TMHP procedure code 1-T1015 for $45 and would be reimbursed at the center s encounter rate. Reminder: An encounter is defined as a face-to-face meeting between a client and a physician, physician assistant, NP, CNS, certified nurse midwife (CNM), psychologist, social worker, or a visiting nurse. All services (except for family planning, THSteps medical, THSteps dental, immunizations, and case management for high-risk pregnant women and infants) provided during an encounter must be billed using procedure code 1-T1015. Laboratory and radiology services or the services of a licensed vocational nurse (LVN), registered nurse (RN), nutritionist, or dietitian are not considered an encounter, because they are incidental to an encounter with one of the above-mentioned health care professionals. Providers should continue to include the cost associated with these services on their cost report (they are allowable but do not constitute an encounter). When an FQHC sees a client younger than 21 years of age for immunizations that are not part of a THSteps checkup, the FQHC should bill for the administration of the immunization on the HCFA-1450 (UB-92) or CMS-1500 claim form using their FQHC provider identifier and the appropriate Medicaid procedure code. If the client is seen only for immunizations, an encounter should not be billed. There is no change in the billing procedures for those services noted as exceptions. The total billed amount for the service should be the total charge for all services provided during the encounter or incident to the encounter. Claims should be filed as follows: Services CPW case management services THSteps dental services THSteps medical services Claim Form HCFA-1450 (UB-92) or CMS-1500 claim form American Dental Association (ADA) claim form CMS-1500 claim form. All claims must be filed using the FQHC provider identifier. Services provided by a health care professional require one of the following modifiers with procedure code 1-T1015, to designate the health care professional providing the services: AH, AM, SA, TD or TE with place of service (POS) 2, or U7. If more than one health care professional is seen during the encounter, the modifier should indicate the primary contact. The primary contact is defined as the health care professional who spends the greatest amount of time with the client during that encounter. If the encounter is for antepartum care or postpartum care, the modifier TH must be indicated. The electronic format or the paper claim form allows for multiple modifiers; therefore, if the antepartum or postpartum care or delivery is provided by a CNM, then modifier SA must be indicated on the claim in addition to the appropriate modifier above. If a physician of the FQHC provides a service in the hospital such as delivery, the FQHC may elect to bill for that service using the physician s provider identifier, if the contract with the physician indicates this occurrence. If the service is billed using the physician number rather than the FQHC s provider identifier, the costs associated 21 CPT only copyright 2005 American Medical Association. All rights reserved. 21 3

4 Section 21 with the service must be excluded from the cost report and will not be considered during the cost settlement/ encounter rate setting process. Refer to: The following sections for benefit limitation information: Benefits and Limitations on page 36-8 in the Physician section. Benefits and Limitations on page 38-2 in the Psychologist section. Benefits and Limitations on page 19-9 in the Dental section. Benefits and Limitations on page 10-2 in the Birthing Center section. Benefits and Limitations on page 31-2 in the Maternity Service Clinic section. Benefits and Limitations on page 12-2 in the Case Management for Children and Pregnant Women (CPW) section. Benefits and Limitations on page 29-2 in the Licensed Marriage and Family Therapist (LMFT) section. Benefits and Limitations on page 28-2 in the Licensed Clinical Social Worker (LCSW) section. Benefits and Limitations on page 30-2 in the Licensed Professional Counselors (LPCs) section. Benefits and Limitations on page 45-2 in the VIsion Care (Optometrists, Opticians) section Telemedicine A remote site provider can be an FQHC, RHC, or health care provider such as a physician, APN, or CNM who is able to independently bill the Texas Medicaid Program for an office visit. FQHC telemedicine providers must submit their claims using the appropriate encounter code and modifiers. Use modifier AM, U7, or SA in the first modifier field on the claim form with the modifier GT in the second modifier field. Refer to: Telemedicine Services on page for more information Newborn Eligibility Process for FQHCs A child is deemed eligible for Medicaid for up to one year if: The mother is receiving Medicaid at the time of the child s birth and If the child continues to live with the mother and if the mother continues to be eligible for Medicaid or would be eligible for Medicaid if she were pregnant. Therefore, it is not acceptable to require a deposit for newborn care from a Medicaid client. The child s eligibility ceases if the mother relinquishes her parental rights or if it is determined that the child is no longer part of the mother s household. Important: Filing a claim for a newborn client under the mother s client number can delay a claim payment. Note: When billing for a Medicaid Managed Care client, providers must adhere to the client s health plan s guidelines for newborn billing. Claims with charges for newborn care are submitted separately from charges for the mother. Claims submitted for services provided to a newborn child should be filed using the newborn child s Medicaid number. To expedite the claims processing, enter the mother s name in Block 84 of the Remarks field of the HCFA-1450 (UB-92) claim form. Include this information in Block 4 of the CMS To provide information about each child born to a mother eligible for Medicaid, FQHCs with birthing centers should complete Form 7484 Hospital Report of Newborn Child or Children. If the newborn s name is known, include it on the form. The use of Baby Boy or Baby Girl delays the assignment of a number. Filing this form expedites the assignment of a Medicaid number for the newborn child. Do not complete this form for stillbirths. The FQHC should complete the form within five days of the child s birth and send it to DSHS. This five-day time frame is not mandatory; however, prompt submission will expedite the process of determining the child s eligibility. FQHCs should duplicate the form as needed because HHSC and TMHP do not supply this form. Upon receipt of a completed form, DSHS verifies the mother s eligibility and sends notices within ten days to the hospital or birthing center, attending physician (if identified), mother, and caseworker. The notice includes the child s Medicaid number and the effective date of coverage. HHSC will issue a client Medicaid Identification form (Form H3087) after the child has been added to the eligibility file. The attending physician s notification letter is sent to the address on file for the license number at the Texas Medical Board. This address must be kept current to ensure timely notification of attending physicians. Physicians should submit address changes to the following address: Texas Medical Board Customer Information, MC-240 PO Box 2018 Austin, TX Hospital Report (Newborn Child or Children) HHSC Form 7484 on page B Claims Information FQHC services must be submitted to TMHP in approved electronic format or on a HCFA-1450 (UB-92) or CMS-1500 claim form. When filing claims for clients who only have Medicaid, providers may use either a 21 4 CPT only copyright 2005 American Medical Association. All rights reserved.

5 Federally Qualified Health Center (FQHC) HCFA-1450 (UB-92) or CMS-1500 claim form. When filing claims for THSteps medical services, providers must use the CMS-1500 claim form and not the HCFA-1450 claim form. For providers who also have Titles V, X, and XX funding, family planning claims are filed on the Family Planning 2017 Claim Form on page When filing for a client who has Medicare and Medicaid coverage, providers must file on the same claim form that was filed to Medicare. Providers may purchase claim forms from the vendor of their choice. TMHP does not supply them. The THSteps Dental (ADA) claim form described under FQHC services, Family Planning, Case Management for Children and Pregnant Women, and THSteps services may be submitted electronically Claim Filing Resources Refer to the following sections and/or forms when filing claims: Page Resource Number Automated Inquiry System (AIS) xiii TMHP Electronic Data Interchange (EDI) 3-1 CMS-1500 Claim Filing Instructions 5-24 HCFA-1450 (UB-92) Claim Filing Instructions 5-32 Dental (ADA) Claim Filing Instructions 5-43 TMHP Electronic Claims Submission 5-10 Communication Guide A-1 Federally Qualified Health Center Report (Newborn Child or Children) Form 7484 B-40 Medicaid Audit Request for Claims Summary B-54 FQHC Encounter (T1015) Claim Example D-14 FQHC Follow-Up Claim Example D-14 Acronym Dictionary F-1 CPT only copyright 2005 American Medical Association. All rights reserved. 21 5

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