1. FQHC Billing Basics for Behavioral Health Partners
Presented by:
Kathleen Reynolds, LMSW, ACSW

2. Overview FQHC Billing Mechanisms Implication of FQHC Mechanisms
Two Services in One Day
Health and Behavior Assessment Intervention Codes
340B Pharmacy Benefits
Uninsured

3. FQHC Billing Mechanisms
PPS – Prospective Payment System
Cost Based Reimbursement
330 Funding
Scope of Service (Changes)
Mirror scope of primary location to the behavioral health location
Original scope has to include Behavioral Health or apply to have it included
Allows for FQHC to bill for primary care services not able to be billed by CMHC

4. Implications of FQHC Billing Mechanisms
FQHC/CHC bill by encounter rates and receive the same amount of funding for a 10 minutes visit as they do for a 1 hour visit
Contracting with FQHC/CHC’s
Leasing Options for staff
Psychiatrists
Consulting Psychiatrist Model
LICSW/LMSW

5. Two Services in One Day
Myth: The federal government prohibits this or Medicaid won’t pay for this!
Reality: This is a state by state Medicaid issue, not a federal rule or regulation – Georgia does not allow two services in one day to be billed
Federal Citations:
Medicare will cover a physical health and mental health visit same day/same provider – CFR Title 42 Volume 2, Part 405. Section
Medicaid confirmation received from Peggy Clark, (CMS/CMSO) – “In terms of FQHC’s/RHC’s there are no applicable, current (federal) Medicaid regulations, but some States follow Medicare requirements pertaining to same day billing. In terms of same day billing in the Community Mental Health Centers and Outpatient Hospital setting, there are no specific Medicaid statutes or regulations on this matter.

6. Two Services in one Day
Medicaid is currently billable in 28 states by one provider
Two providers can bill for the services they provide on the same day – Contractual Business Model
Behavioral Health Provider bills for BH service under their provider number
Primary Care bills for their services under their provider number

8. The Health and Behavior Assessment/Intervention Codes (96150 - 96154)
Approved CPT Codes for use with Medicare right now
Some states are using them now for Medicaid
State Medicaid programs need to “turn on the codes” for use
Behavioral Health Services “Ancillary to” a physical health diagnosis
Diabetes
COPD
Chronic Pain

10. 340B Pharmacy Benefits 340B Pharmacy benefits
Individual receiving services enrolled in FQHC/CHC
Broader formulary
Significantly reduced rate
Consumer needs to be enrolled with the FQHC/CHC
Prescription needs to be written by/cosigned by an FQHC physician

11. Uninsured FQHC/CHC federal funding to cover uninsured
Increased # of insured can help offset cost of uninsured
State Health Plans
Discuss the ability to add a Behavioral Health Benefit
Partner with Universities to be Student Teaching location
3rd year medical students
Nurse Practitioners
Masters of Social Work

12. CONTACT INFORMATION Kathy Reynolds, LMSW, ACSW