Federally Qualified Health Centers & Rural Health Centers. April 2016

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1 Federally Qualified Health Centers & Rural Health Centers April 2016

2 Disclaimer The information contained in this presentation was current at the time it was written. It was prepared as a tool to assist providers and is not intended to be all inclusive, grant rights, impose obligations, or function as a stand-alone document. Although every reasonable effort has been made to assure the accuracy of the information within the presentation, the ultimate responsibility for understanding Medicaid program regulations lies with the provider of services. The State of Alaska Department of Health and Social Services and Conduent, Incorporated employees and staff make no representation, warranty or guarantee that this compilation of information is error-free and/or comprehensive and will bear no responsibility or liability for the results or consequences of the use of this guide. 2

3 Overview Provider Enrollment Member Eligibility Covered Services Billing Additional Information 3

4 Provider Enrollment 4

5 Health Clinics Alaska Medicaid will pay for covered services provided to an enrolled member if the health clinic: Meets the requirements of 42 CFR Is enrolled as a federally qualified health center (FQHC) or a rural health clinic (RHC) Is enrolled as a Medicare provider Is not enrolled as another type of Medicaid provider of primary care or ambulatory services Employs staff who meet provider requirements for the services provided 5

6 Health Clinics Health clinics must enroll and bill separately for the following services: Dispensing pharmacy Nurse midwife or direct entry midwife If a health clinic operates in more than one site in the state, each site must enroll separately and meet the requirements Health clinics must maintain sufficient financial records and statistical data to allow the department to identify and verify the costs and charges associated with providing services at each site A health clinic may terminate its provider agreement to participate as an RHC or FQHC by submitting a written notice to the department and identifying a termination date not less than 30 days after submitting the notice of termination 6

7 Federally Qualified Health Center To qualify as an FQHC, the provider must meet at least one of the following eligibility requirement for the entire period for which Medicaid services are rendered: Receiving a grant as: Migrant Health Center Community Health Center Health Care for the Homeless Receiving money from a grant listed above under a contract with the grant recipient and also meets the requirements for receiving a grant Determined by the US DHHS/CMS to meet requirements for receiving a grant Is a hospital or clinic operated by a tribal organization In addition to these requirements, an FQHC must Participate as an FQHC Provide the department with a letter from CMS certifying the provider as an FQHC and a copy of its grant notice (Tribal health programs are exempt from providing documentation of certification) 7

8 Rural Health Clinics An RHC is a clinic located in a rural, underserved area that has received federal designation as an RHC RHCs may not be a rehabilitation facility or a facility primarily for the care and treatment of mental diseases All RHCs must maintain sufficient financial records and statistical data to allow the department to identify and verify the costs and charges associated with providing services at each site 8

9 Recordkeeping Recordkeeping requirements are documented in the Individual Provider Agreement and Tax Certification and Group Provider Agreement and Tax Certification Although most recordkeeping requirements are consistent for all providers, some requirements are provider-type specific Providers must maintain complete and accurate clinical, financial, and other relevant records to support the care and services for which they bill Alaska Medical Assistance for a minimum of 7 years from the date of service Providers are subject to audits, reviews and investigations Providers must ensure their staff, billing agents, and any other entities responsible for any aspect of records maintenance meet the same requirements. 9

10 Member Eligibility 10

11 Member Eligibility Always verify member eligibility by using one of the following options: Request to see the member's eligibility coupon or card that shows the current month of eligibility; photocopy for your records Call Automated Voice Response System (AVR): (toll-free) Verify via Alaska Medicaid Health Enterprise website Fax complete Recipient Eligibility Inquiry Form - General Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction Call Provider Inquiry , option 1 or , option 1, 1 (toll-free) 11

12 Member Eligibility Code Category FQHC RHC 11 Medicaid for Pregnant women X X 15 Pregnancy or incapacity determination exam X 20 Family Medicaid or APA related Medicaid X X 21 Chronic or Acute Medicaid (CAMA) coverage X X 24 Institutional Long Term Care Medicaid X 25 Disability/blindness exam X 30/31 Waiver for adults with physical and developmental disabilities X X 34 Waiver APA/QMB X X 40/41 Older or disabled adult with waiver and Medicaid X X 44 Older or disabled adult with waiver Medicaid, APA and QMB X X 50 Medicaid for children under 21 who are not in state custody X X 12

13 Member Eligibility Code Category FQHC RHC 51 Medicaid for children under 21 who are in state custody, including Title IV-E foster care 52 4 months of Medicaid for members otherwise ineligible due to earned income 53 Emergency Alien Medicaid X 54 Medicaid-only for disabled child receiving SSI X X 67 QMB Eligible for payment of Medicare deductibles and copays and payment of Medicare Part A and B monthly premiums only 69 APA/QMB full Medicaid and QMB X X 70/71 IDD Waiver X X 74 IDD waiver, APA and Medicare X X 80/81 Medically complex children-waiver X X X X X X X X 13

14 Covered Services 14

15 Covered Services FQHCs and RHCs may receive payment only for services provided to a patient of the clinic by an employee or contract worker of the clinic Providers will be paid the encounter rate per visit for a Medicaid eligible member for: Primary and ambulatory care Mental health services Visit means the aggregate of face-to-face encounters, occurring on the same calendar day and at a single location, between the member and one or more clinic professionals 15

16 Primary Care Services Primary care services are covered if delivered by a physician, PA or ANP, acting within scope of their license. Health education and disease prevention Initial assessment of health problems Treatment of acute and chronic health problems Overall management of care services 16

17 Ambulatory Services Covered services under the categories listed here can also be covered for FQHCs and RHCs when rendered by appropriate providers acting within the scope of their licensure Vision services Private-duty nursing Speech-language pathology Hospice Hearing Family planning EPSDT screening and services Physical and occupational therapy Podiatry Chiropractic Non-primary care services that are Nutrition provided in a hospital by a rural health clinic physician, PA or ANP acting within the scope of that individual s license to practice Ambulatory services rendered at the same time and location as other ambulatory services and/or primary care services, would be considered covered under the same encounter rate 17

18 Separate Payment The department will pay an FQHC/RHC separately for: Labor and delivery services If services are provided by a separately enrolled physician/pa, ANP or nurse midwife Payment is made in accordance with relevant fee schedule Pharmacy services and prescription drugs If the clinic is separately enrolled as a dispensing provider Payment is made in accordance 7 AAC AAC

19 Mental Health Services The department will pay the established encounter rate to a FQHC/RHC for the following covered behavioral health services, when provided by a psychologist or licensed clinic social worker acting within scope of their license. Psychiatric diagnostic interview procedures Psychological testing and examination services Individual psychotherapy Group psychotherapy Family psychotherapy Health and behavior assessment and intervention services 19

20 Off-Site Services Payment for services delivered off-site are limited to the following: When member is homebound and A shortage of home health agencies exists in the area Services are furnished by an RN, LPN or licensed vocational nurse employed or compensated by the clinic Services are provided under a written plan of treatment Nursing care is limited to covered services An RHC physician provides the services in a hospital or nursing facility An RHC PA or ANP provides the services in a hospital An FQHC physician, PA or ANP provides the services in a nursing facility 20

21 Homebound Patient A member is considered homebound if, due to medical or health condition, the member is confined to their residence, or cannot leave the residence without considerable effort Infrequent, short duration absences will not disqualify an individual from being considered homebound If the member s residence is a hospital or long-term care facility, the department will not consider the member homebound 21

22 Non-Covered Services The department will not pay for: Services the department determines to be incidental to primary care services, including: laboratory services x-ray services supplies Services or supplies that a health clinic routinely provides to individuals other than Medicaid-eligible members Services or supplies that the health clinic routinely furnishes for free or without regard to the member s ability to pay Services provided off-site, except as noted 22

23 Billing 23

24 Claims Submission Methods There are several billing options for Alaska Medical Assistance providers. Alaska Medicaid Health Enterprise 837I Transaction (electronic claim using billing software) Companion Guide: Implementation Guide (referred to as TR3): Payerpath (electronic claim) UB-04, Insitutional Health Insurance Claim Form (paper claim) 24

25 Overpayments & Repayment of Payment Errors Providers should closely review each remittance advice (RA) to ensure it reflects accurate payment for all billed services, including correct member details and services provided. In accordance with 7 AAC (e), Alaska Medical Assistance providers have 30 days from the time of payment to notify the department in writing of a payment error. Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department within 60 days of identifying the overpayment. Mail the written overpayment notification and a copy of the RA page detailing the overpayment to the address below: Conduent State Healthcare, LLC P.O. Box Anchorage, Alaska

26 Timely Filing All claims must be filed within 12 months of the date you provided services to the member The 12-month timely filing limit applies to all claims, including those that must first be filed with a third-party carrier 26

27 Additional Information 27

28 Alaska Medicaid Compliance & Ethics Training Compliance & Ethics: Alaska Medicaid 101 is a computer-based training which includes an interactive video presentation and a supplemental handbook This training serves to: Familiarize providers with the responsibilities and requirements associated with being a Medicaid provider Guide providers through the laws and regulations Medicaid providers must follow The training is available at Select Provider>Compliance & Ethics Alaska Medicaid provides a certificate for completing this training Please direct any questions to the Provider Training department at or

29 Additional Resources Alaska Medicaid Health Enterprise website at Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Provider Inquiry Eligibility only , option 1,2 or (toll-free), option 1,1,2 Claim status and other inquiries , option 1,1 or (toll-free), option 1,1,1 29

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