Federally Qualified Health Centers (FQHCs) provide health care for under-privileged individuals within a specific community. For this reason, FQHCs often struggle with patient billing processes and getting timely payments for their health and medical services.
Below we share some information, resources, and FAQs to help these unique health centers optimized FQHC billing and coding practices for maximized revenue.
A Federally Qualified Health Center (FQHC) is a health facility which is defined by any of the following elements.
When billing the encounter code, bill $0.00. For services eligible for encounter payments, the system will automatically pay the difference between the FQHC encounter rate and the fee-for-service amount paid. For clients in programs eligible for encounter payments, the agency denies Evaluation and Management (E & M) codes when billed without a T1015. When billing for services that do not qualify for encounter payments, do not use an encounter code on the claim form.
When billing for orthodontic services, FQHCs are required to follow the same guidelines as non-FQHC providers. However, orthodontic codes that are considered “global” and therefore cover a specific length of time are billed at the end of the time indicated – except for the initial placement of the device, which is billed on the date of service.
Because FQHCs are reimbursed by an encounter payment, they are allowed to bill up to the maximum number of encounters. An FQHC may bill on the date of the appliance placement for 1 unit and up to a total of 4 units during the first 3 months of the appliance placement.
If a clinic chooses to bill in this manner instead of waiting the full 3 months, the latest paid claim must be adjusted each time, and another unit added to the line containing the T1015 code. If the claim is not adjusted, the claim will be denied as a duplicate billing.
This is common question that many FQHCs ask time and time again. Such ambiguities can be best avoided when working with experienced FQHC billers. Each individual provider is limited to one type of encounter per day for each patient, regardless of the services provided except in the following circumstances:
Each encounter must be billed on a separate claim form. This is a common mistake made during the FQHC billing process. On each claim, to indicate that it is a separate encounter, enter “unrelated diagnosis” and the time of both visits in field 19 on the CMS-1500 claim form, or in the Comments field when billing electronically. Documentation for all encounters must be kept in the client’s file.
FQHCs do not receive an encounter payment when billing a crossover claim. The payment methodology for these claims is spelled out in the ProviderOne Billing and Resource Guide. Note that FQHC crossover claims will not exceed the co-insurance amount. They do not follow the same methodology as other claims.
FQHCs are required to bill crossover claims in the UB04/837I claims format. If Managed Medicare or Medicare Part C require services to be billed on a CMS1500/837P and they are paid or the money is applied to the deductible, FQHCs must switch the claim information to the UB04/837I format or the claim will not process correctly. These crossover claims must be billed to the agency using the Type of Bill 77X and the FQHC taxonomy for the billing provider.