5101:3-28-04 Federally qualified health centers (FQHCs): billable services.

(A) "Billable services" for FQHCs are core and noncore services identified in rule 5101:3-28-02 of the Administrative Code which areand provided in accordance with Chapter 5101:3-28 of the Administrative Code.

(B) Services shall be billed on an encounter basis. An "encounter" is defined as face-to-face contact between a patient and provider(s) of covered core or covered noncore services, except for transportation services.

(1) FQHC services shall be billed on an encounter basis, in accordance with rule 5101:3-4-02 of the Administrative Code.

(2) The services of a registered nurse shall be billed as a medical encounter unless provided "incident to" a medical encounter as described in paragraph (B)(3) of this rule.

(3) Encounters with more than one health professional for the same type of service (e.g., a nurse and a physician provide a medical service) and multiple interactions with the same health professional that take place on the same day and at a single location constitute a single encounter except when the patient, after the first interaction, suffers illness or injury requiring additional diagnosis and treatment.

(4) Each type of service, as set forth in paragraphs (A)(1) to (A)(3) and (B) of rule 5101:3-28-03 of the Administrative Code, is separately billable regardless of whether the encounters occur on separate days or the same day(e.g., a physician and a dentist provide different types of services).

(5) "Billable encounters" are encounters that:

(a) Take place at a service site approved by public health services as part of an FQHC; or

(b) Take place in a patient's home or outpatient hospital setting for the purpose of providing services to FQHC patients; and

(c) Are documented in the patient health records in accordance with rule 5101:3-1-27 of the Administrative Code.

(6) For dates of service on and after the effective date of coverage of denture follow-up encounters in accordance with paragraph (B)(3) of rule 5101:3-28-03 of the Administrative Code, to receive reimbursement for a denture follow-up encounter, the FQHC shall submit a claim with the following information:

(a) Enter the code T1015 modified by U2 to indicate this is a billing for dental services.

(b) On the next line of the claim, bill D0140 modified by TS to indicate that this is a follow-up visit for a denture service that was previously prior authorized by the department.

(7) Transportation services shall be billed on a unit basis. Each trip to or from the service site shall be counted as a unit of transportation service.

(8) Consultations with anyone other than the patient are not considered encounters, and are therefore not billable.

(9) Each FQHC service site must obtain and use its own separate medicaid provider number.

(a) An FQHC service site may not use the provider number of another FQHC service site, even another service site within the parent organization.

(b) Services provided away from the FQHC service site, such as in an individual's home, must be associated with a specific FQHC service site and must be billed using the provider number of the FQHC service site held accountable for the delivery of the services.

(C) The following services are not billable under a provider's FQHC provider number. These services should be billed by an FQHC under a different medicaid provider number as a fee-for-service ambulatory care provider:

(1) Inpatient hospital surgery;

(2) Inpatient hospital visits or consultations;

(3) Medicare crossover claims that are not paid through the automatic medicare crossover process in accordance with rule 5101:3-1-05 of the Administrative Code;

(4) Disability assistance program claims;

(5) Take home drugs shall be billed through the pharmacy program as described in Chapter 5101:3-9 of the Administrative Code; and

(6) Durable medical equipment (DME) for take-home use shall be billed through the DME program as described in Chapter 5101:3-10 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/09/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/10/91, 3/1/02