FQHC Reimbursement Billing Guidelines
Summary:
In order to align our current Ambetter contracts with how CMS pays FQHC encounters, we have made changes to our configuration for FQHCs.
Details:
Based on our alignment with CMS, these are the notable changes to our billing guidelines for FQHCs:
- Require encounters to be billed on a UB (CMS-1450) (as CMS does). This will ensure the providers are paid their encounter rate for services.
- Non-encounters (adjunct codes) should be billed on a CMS-1500 to align with CMS requirements. Adjunct codes are a limited set of codes that are paid in addition to the encounter. Not all services are eligible to be paid as an adjunct code.
This will bring us into compliance with contract language as well as ensure accurate payment to the provider.
NOTE: This only applies to contracts with PPS language. See examples below, the contract would contain same or similar language.
Example 1:
Example 2:
