Presented by: Denise Hobbs PHN, PSC Shasta County November 2, 2011 Federally Qualified Health Care Centers (FQHCs) Rural Health Clinics (RHC) & CPSP

PSCs need to know the basics!! We need to know –What is an FQHC –How are they different from Fee for Service (FFS) providers –Are they eligible for CPSP bonuses –Do they have to submit TARS

Provide ambulatory health care services to low income, medically underserved populations recipients in rural and non rural areas. FQHC/RHC use the same contracted fiscal intermediary as FFS billing. Paid on a prospective payment system (PPS), which is a flat rate. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

FQHC Billing FQHC’s bill by encounters –Do not bill with CPT codes – use “01” –Bill per visit - an “encounter” They may only bill 1 visit/day –The exception: they may bill for 2 visits if a patient suffers illness or injury on the day of visit or if one visit is a dental visit. A visit is defined as a face to face encounter with a qualified practitioner plus any incidental services.

FQHC Continued FQHC’s/RHC may bill for all CPSP practitioners including the CPHW as defined in Title 22 CCR Section FQHC’s do not receive CPSP bonuses Case Coordination Fee Group Classes – bill for only one patient Do not spread out services on multiple days

Treatment Authorization Requests (TAR) DO FQHCs have to submit TARs? –Do not submit to M/C –Document TAR requirements and keep in chart –Cannot provide additional prenatal visits –Use CPSP Billing Summary Form

Chart Documentation Documentation requirements include: 1.Expected date of delivery (EDC) 2.Clinical findings of the high-risk factors involved in the pregnancy 3.Explanation of why basic CPSP services are not sufficient 4.Description of the services being requested 5.Length of visits and frequency with which the requested services are provided 6.Anticipated benefit of outcome of additional services

Key Points to Remember CPSP services should look the same to the patients in FQHC and fee-for-service sites Documentation is same as FFS Same maximum service allowances as FFS FQHCs bill Medi-Cal as a code “01” for straight Medi-Cal claims. Medi-Cal reimburses their encounter rate. FQHC/RHC must bill Medi-Cal Manage Care (MCMC) or Health Care Plan first for services.

Resources MCAH Policies & Procedures Medi-Cal Manual Part II PSC’s Contact information can be found on the State MCAH CPSP website