[
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Office visits / encounter payment",
    "codes": "G0466, G0467, G0468, G0469, G0470",
    "question": "How does Medicare pay an FQHC for an office visit?",
    "answer": "Medicare pays FQHCs a per-visit PPS rate. The claim carries an FQHC payment code (G0466-G0470) plus the qualifying-visit line(s). Payment is the lesser of the center's charge for the payment code or the PPS rate, adjusted by the locality's geographic adjustment factor (GAF). Medicare pays 80% and the patient owes 20% coinsurance; the Part B deductible does not apply to FQHC services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.3 (payment calculation); §40.1-40.2 (deductible/coinsurance)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-001",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Claim form / type of bill",
    "codes": "TOB 077X; frequency 0,1,7,8",
    "question": "What claim form and type of bill does an FQHC use for Medicare?",
    "answer": "FQHCs bill Medicare institutionally on the 837I (paper CMS-1450/UB-04 only when permitted) using type of bill 77X. Frequency codes listed include 0, 1, 7 and 8. A claim cannot span two calendar years.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§50 (general billing); §100 (claims spanning years)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-002",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Revenue codes",
    "codes": "0521, 0522, 0524, 0525, 0527, 0528, 0519, 0900",
    "question": "Which revenue codes go with FQHC Medicare payment codes?",
    "answer": "Medical payment codes G0466, G0467 and G0468 are reported under revenue code 052X (e.g., 0521, 0522, 0524, 0525, 0527, 0528); mental health payment codes G0469 and G0470 under revenue code 0900. Medicare Advantage supplemental (wrap) claims use revenue code 0519.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§50; §60.2 (effective 10-01-26)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-003",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Payment codes",
    "codes": "G0466, G0467, G0468, G0469, G0470",
    "question": "What do the five FQHC payment codes G0466-G0470 represent?",
    "answer": "In plain terms: G0466 = medical visit, new patient; G0467 = medical visit, established patient; G0468 = IPPE or Annual Wellness Visit; G0469 = mental health visit, new patient; G0470 = mental health visit, established patient. 'New' means the patient has not received any professional service from any site within the FQHC organization in the past 3 years.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS - Specific Payment Codes for the FQHC PPS (dated 12-06-17)",
    "source_url": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf",
    "source_section": "Payment code definitions (p.1)",
    "last_verified": "2026-10-30",
    "confidence": "High for definitions - the CMS list is dated 12-06-17 but is still the payment-codes document linked from the current CMS FQHC Center page (checked 2026-10-30).",
    "id": "MED-004",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Qualifying visits",
    "codes": "99202-99205, 99212-99215, 90791, 90792, 90832, 90834, 90837, 90839, 90845, 92002, 92004, 92012, 92014, 97802, 97803, G0101, G0102, G0402, G0438, G0439, G0442-G0447, 99495, 99496, 99304-99310, 99341-99350",
    "question": "Does the G-code alone get paid, or do I need a qualifying visit line?",
    "answer": "A payment code must be billed together with a qualifying-visit line (a HCPCS/CPT code on CMS's qualifying visit list) and all services furnished that day go on the same claim. CMS's published qualifying-visit list includes code numbers such as 99202-99205, 99212-99215, 90791/90792, 90832/90834/90837, 92002-92014, 97802/97803, G0101/G0102, G0402, G0438/G0439 and transitional care codes 99495/99496.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.2; code list from 'Specific Payment Codes for the FQHC PPS'",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the qualifying-visit list (dated 12-06-17) is still linked from the current CMS FQHC Center, but it has not been updated for later code changes (e.g., 99201 deleted 2021; MFT/MHC services added 2024); check before relying on a specific code.",
    "id": "MED-005",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "New patient adjustment",
    "codes": "G0466, G0469, G0468",
    "question": "When does Medicare pay the higher new-patient / IPPE-AWV rate?",
    "answer": "The PPS rate is multiplied by an adjustment factor of 1.3416 when the patient is new to the FQHC (not seen anywhere in the organization within 3 years) or when the FQHC furnishes an IPPE or Annual Wellness Visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§30.2",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-006",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Same-day medical + mental health",
    "codes": "G0466, G0467, G0468 + G0470 (or G0469)",
    "question": "Can an FQHC get paid for a medical visit and a mental health visit on the same day?",
    "answer": "Yes. A medical visit and a mental health visit on the same day are separately payable. Bill the medical payment code (G0466/G0467/G0468) under 052X and the mental health payment code under 0900, each with its qualifying visit, on one claim. CMS's code guidance says a new patient seen for both on the same day is billed G0466 plus G0470 (not G0469).",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§30.1 (exceptions to one visit per day); §60.2; CMS payment-codes guidance",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-007",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Same-day subsequent illness",
    "codes": "G0467-59",
    "question": "How do I bill a second medical visit on the same day for a new illness or injury?",
    "answer": "When, after the first visit, the patient suffers an illness or injury needing additional diagnosis or treatment, the second visit is billed as G0467 with modifier 59. Modifier 59 is used only in this situation with G0467. Otherwise multiple encounters the same day count as one visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§30.1; §50; §60.2",
    "last_verified": "2026-10-30",
    "confidence": "High. Note: Ch. 9 does not describe a modifier 25 convention for FQHC PPS claims; modifier 25 rules in Medicaid manuals do not carry over.",
    "id": "MED-008",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Preventive / IPPE / AWV",
    "codes": "G0468, G0402, G0438, G0439; rev 0771",
    "question": "How are IPPE, Annual Wellness Visits and other preventive services billed?",
    "answer": "IPPE and AWV are billed with payment code G0468 plus the qualifying IPPE/AWV code. Coinsurance is waived for Medicare-covered preventive services recommended with a USPSTF grade A or B. CMS's billing example puts G0468 on a 0521 line (carrying total charges) and the preventive service code (e.g., G0439) on a 0771 line; coinsurance is not applied to the preventive line. The professional component of an EKG is included in the PPS; the technical component is billed on the CMS-1500/837P under the practitioner's ID. An IPPE does not get a separate payment when billed the same day as another visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§70.2 (preventive services); §70.5 (IPPE); §30.1",
    "last_verified": "2026-10-30",
    "confidence": "High.",
    "id": "MED-009",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Vaccines",
    "codes": "Pneumococcal, influenza, hepatitis B, COVID-19 vaccines; M0201",
    "question": "How does Medicare pay FQHCs for vaccines?",
    "answer": "Effective July 1, 2025, pneumococcal, influenza, hepatitis B and COVID-19 vaccines and their administration are paid at the time of the claim (not only through the cost report), do not require a visit, and have no coinsurance. If reported the same day as a visit, they are paid separately. Payments are reconciled annually through the cost report. M0201 is the add-on for in-home vaccine administration.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.2; §70.3 (preventive vaccines)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-010",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Care management (CCM/BHI/APCM)",
    "codes": "G0511, G0556, G0557, G0558; rev 052X",
    "question": "Is G0511 still billable for chronic care management or behavioral health integration?",
    "answer": "No. Starting 1/1/2025 FQHCs bill the individual care management codes; G0511 was accepted only during a transition that ended 9/30/2025, and CMS now lists G0511 as terminated. G0512 (CoCM) and G0071 are not reportable from 1/1/2026. Advanced Primary Care Management codes G0556-G0558 are available, with optional add-ons G0568-G0570 from 2026. From 1/1/2026 designated care management codes are reported on revenue code 052X and paid at the national non-facility PFS rate. Transitional care management can count as a qualifying visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.8; CMS FQHC News page (CY 2026 PFS highlights)",
    "last_verified": "2026-10-30",
    "confidence": "High - Ch. 9 Rev. 13803 §60.8 confirmed by the CMS FQHC News page (modified 10/29/2026).",
    "id": "MED-011",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Virtual communication",
    "codes": "G0071 (ended); individual codes",
    "question": "How do FQHCs bill virtual check-ins and remote evaluations in 2026?",
    "answer": "G0071 ended 1/1/2026. FQHCs now bill the individual virtual communication service codes as defined under the Physician Fee Schedule instead.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.7",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-012",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Telehealth (non-mental health)",
    "codes": "G2025, Q3014; rev 0780; modifier CS",
    "question": "Can an FQHC bill Medicare for telehealth in 2026?",
    "answer": "Yes. FQHCs may bill non-behavioral telehealth (including audio-only to the home) through 12/31/2027. Through 9/30/2026 these were billed with G2025; from 10/1/2026 FQHCs report the individual CPT/HCPCS telehealth code with modifier 95 (audio-video) or 93 (audio-only), paid at the CY 2026 rate of $97.53. As an originating site, the FQHC can bill Q3014 under revenue code 0780 (subject to deductible and coinsurance). Modifier CS applies where cost sharing is waived for specified services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Telehealth FAQ (updated 10-09-2026)",
    "source_url": "https://www.cms.gov/files/document/telehealth-faq-updated-10-09-2026.pdf",
    "source_section": "Q4, Q6; CMS FQHC News page; Claims Manual Ch. 9 §80 (Q3014, CS)",
    "last_verified": "2026-10-30",
    "confidence": "High - CMS Telehealth FAQ (10-09-2026) and CMS FQHC News page (10/29/2026). Benefit Policy Ch. 13 (Rev. 13600) still shows 12/31/2026 and Ch. 9 §80 still describes G2025; the newer CMS pages govern.",
    "id": "MED-013",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Mental health via telecommunications",
    "codes": "G0469, G0470; modifiers 95, 93",
    "question": "Can mental health visits be furnished by video or audio-only?",
    "answer": "Yes. A mental health visit can be a real-time audio-video encounter (modifier 95), or audio-only (modifier 93) when the patient cannot use or does not consent to video; it is billed like an in-person mental health visit (G0469/G0470 under 0900). The in-person visit requirement (within 6 months before, then every 12 months) will not take effect until after January 1, 2028, per CMS's current FQHC guidance.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS FQHC/RHC News & Announcements - CY 2026 PFS Final Rule highlights (page last modified 10/29/2026)",
    "source_url": "https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/information-centers/federally-qualified-health-centers/news-announcements",
    "source_section": "Telecommunications Services bullet; CMS Telehealth FAQ (10-09-2026) Q5; BP13 §170 (modifiers)",
    "last_verified": "2026-10-30",
    "confidence": "High - read on the CMS FQHC News page (10/29/2026) and Telehealth FAQ. Conflict: BP13 §170 (Rev. 13600) still says 1/31/2026 and 42 CFR 405.2469(d) says 10/1/2025; the newer CMS guidance reflects later law.",
    "id": "MED-014",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Group therapy / IOP",
    "codes": "Rev 0905; condition code 92",
    "question": "Is group psychotherapy a billable FQHC visit, and how is IOP billed?",
    "answer": "Group mental health services do not count as a visit. From 1/1/2024, group therapy can be paid as part of an intensive outpatient program (IOP). IOP is billed on TOB 77X under revenue code 0905 with condition code 92, with at least one code from CMS's IOP primary-service list. No FQHC payment code or qualifying visit is needed. Mental health visit plus IOP on the same day pays one IOP-rate payment. Do not report IOP on revenue code 0900.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§170; §250 (IOP); Claims Manual Ch. 9 §110",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-015",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Medicare Advantage wrap",
    "codes": "Rev 0519",
    "question": "How does an FQHC get the Medicare Advantage supplemental (wrap) payment?",
    "answer": "When the MA plan pays less than the FQHC would get under PPS, Medicare pays the difference (PPS rate minus the MA contract amount). The supplemental claim uses revenue code 0519. Do not mix 0519 lines with 052X/0900 lines on the same claim. See the Medicare Advantage entries (MA-001 onward) for the law, calculation examples and plan rules.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.4-60.5",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-016",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Lab / ancillary",
    "codes": "Venipuncture; lab",
    "question": "Is lab billed separately to Medicare by an FQHC?",
    "answer": "Lab tests are not part of the FQHC visit and are billed separately under the applicable payment system. Venipuncture is included in the visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§90",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-017",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Hospice",
    "codes": "Modifier GV",
    "question": "How does an FQHC bill attending physician services for a hospice patient?",
    "answer": "When the FQHC's attending physician/NP/PA (not employed or paid by the hospice) furnishes hospice attending services, report modifier GV on the payment-code line (G0466-G0470) each day. Only coinsurance applies on FQHC claims.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.6",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-018",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Telehealth (non-mental health)",
    "codes": "Individual telehealth CPT/HCPCS codes; modifiers 95, 93; G2025 (through 9/30/2026)",
    "question": "How does an FQHC bill Medicare for distant-site telehealth starting October 1, 2026?",
    "answer": "Through September 30, 2026, FQHCs billed non-behavioral telehealth with the single code G2025. Beginning October 1, 2026, FQHCs bill the individual CPT/HCPCS code that describes the distant-site telehealth service (codes on CMS's Medicare telehealth services list) with modifier 95 (real-time audio-video) or 93 (audio-only). Payment stays at the volume-weighted average of PFS telehealth payments; the CY 2026 FQHC/RHC distant-site rate is $97.53. Non-behavioral telehealth by FQHCs is allowed through December 31, 2027, and the home or any location can serve as distant and originating site for these services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS FQHC/RHC News & Announcements - CY 2026 PFS Final Rule highlights (page last modified 10/29/2026)",
    "source_url": "https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/information-centers/federally-qualified-health-centers/news-announcements",
    "source_section": "Telecommunications Services bullets (CY 2026 PFS final rule highlights); see also CMS Telehealth FAQ 10-09-2026 Q4",
    "last_verified": "2026-10-30",
    "confidence": "High - read on the CMS FQHC News page (modified 10/29/2026) and Telehealth FAQ (10-09-2026). Note: Claims Manual Ch. 9 §80 (Rev. 13803) still describes G2025.",
    "id": "MED-019",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Telehealth (non-mental health)",
    "codes": "Q3014; rev 0780",
    "question": "Can an FQHC bill Medicare as the telehealth originating site, and does the deductible apply?",
    "answer": "Yes. When the patient is at the FQHC and the practitioner is elsewhere, the FQHC bills the originating-site facility fee Q3014 under revenue code 0780. No FQHC payment code or qualifying visit is needed when this is the only service on the claim. Telehealth originating-site services are the only FQHC claim services subject to the Part B deductible; coinsurance also applies.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§80",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 Rev. 13803.",
    "id": "MED-020",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Telehealth (non-mental health)",
    "codes": "Modifiers BB, BC",
    "question": "Are the new telehealth modifiers BB and BC required from January 1, 2027?",
    "answer": "CMS's telehealth FAQ says modifiers BB (telehealth furnished through a virtual platform the practitioner contracts with or has a payment arrangement with) and BC (telehealth furnished incident to a practitioner's service) are required beginning January 1, 2027, and have no payment implications.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Telehealth FAQ (updated 10-09-2026)",
    "source_url": "https://www.cms.gov/files/document/telehealth-faq-updated-10-09-2026.pdf",
    "source_section": "Q17-Q18",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the FAQ is general Medicare telehealth guidance and does not say how BB/BC apply on FQHC (TOB 77X) claims; confirm with your MAC before 1/1/2027.",
    "id": "MED-021",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Mental health via telecommunications",
    "codes": "G0469, G0470; modifiers 95, 93",
    "question": "Can an FQHC furnish audio-only mental health visits at home after 2027?",
    "answer": "Audio-only telehealth to patients at home is allowed through December 31, 2027. From January 1, 2028, audio-only may be used for behavioral health services to a patient at home when the practitioner can do audio-video but the patient cannot use or does not consent to video. For FQHC mental health visits where the patient is present virtually, CMS says in-person requirements will not apply until at least January 1, 2028; patients who began home mental health telehealth before then are treated as established and need an in-person visit every 12 months after December 31, 2027.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Telehealth FAQ (updated 10-09-2026)",
    "source_url": "https://www.cms.gov/files/document/telehealth-faq-updated-10-09-2026.pdf",
    "source_section": "Q5-Q6",
    "last_verified": "2026-10-30",
    "confidence": "High - read in CMS Telehealth FAQ (10-09-2026). Conflict noted: Benefit Policy Ch. 13 §170 (Rev. 13600) and 42 CFR 405.2469(d) still show earlier dates.",
    "id": "MED-022",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Virtual communication",
    "codes": "Individual virtual communication CPT/HCPCS codes (e.g., 98016); G0071 (ended 12/31/2025); G2012 (terminated 12/31/2024)",
    "question": "What are the Medicare requirements for an FQHC to bill a virtual communication service?",
    "answer": "At least 5 minutes of communications-based technology or remote evaluation by an FQHC practitioner, for a patient with a billable FQHC visit in the previous year; the discussion must not relate to an FQHC service in the previous 7 days and must not lead to an FQHC service within the next 24 hours or soonest available appointment (otherwise it is bundled into the PPS). Consent may be obtained by auxiliary staff under general supervision. From January 1, 2026, report the individual CPT/HCPCS base and add-on codes, paid at national non-facility PFS rates; do not put G0071 and the individual codes on the same claim. G2012 was replaced by 98016. Coinsurance is 20% of the lesser of charges or the payment rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§240; §90 (coinsurance)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Benefit Policy Ch. 13 Rev. 13600.",
    "id": "MED-023",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Care management (CCM/BHI/APCM)",
    "codes": "Designated Care Management Services list: 99426, 99427, 99439, 99457, 99458, 99470, 99484, 99487, 99489, 99490, 99492, 99493, 99494, 99495, 99496, G0019, G0022, G0023, G0024, G0140, G0146, G0323, G2086, G2087, G2088, G2214, G0556, G0557, G0558, G0568, G0569, G0570",
    "question": "Which care management codes can an FQHC bill to Medicare in 2026, and how are they paid?",
    "answer": "From January 1, 2026, FQHCs bill care coordination services established under the PFS as 'designated care management services', paid separately at the national non-facility PFS rate (TCM excepted - it can be a visit). The codes are listed in CMS's CY 2026 'Designated Care Management Services Assigned General Supervision' table posted with the PFS final rule; the CY 2026 list is reproduced in the codes field. Auxiliary personnel may furnish them under general supervision.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS CY 2026 PFS Final Rule page (CMS-1832-F) - incl. Designated Care Management Services list",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1832-f",
    "source_section": "CY 2026 Designated Care Management Services table; Benefit Policy Ch. 13 §230",
    "last_verified": "2026-10-30",
    "confidence": "High - code list read in the CMS table downloaded from the CMS-1832-F page; payment basis read on the CMS FQHC News page.",
    "id": "MED-024",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Care management (CCM/BHI/APCM)",
    "codes": "G0512 (ended); 99492, 99493, 99494, G2214; G0568, G0569, G0570",
    "question": "Is G0512 (psychiatric collaborative care) still billable by FQHCs?",
    "answer": "No. G0512 and G0071 are no longer reportable beginning January 1, 2026 (G0511 is also terminated). FQHCs report the individual codes that make up CoCM. FQHCs furnishing APCM (G0556-G0558) may also report optional add-on codes G0568, G0569 and G0570 when they integrate behavioral health integration or CoCM; these are paid at the national non-facility rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS FQHC/RHC News & Announcements - CY 2026 PFS Final Rule highlights (page last modified 10/29/2026)",
    "source_url": "https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/information-centers/federally-qualified-health-centers/news-announcements",
    "source_section": "G0512 and G0071 Changes; Advanced Primary Care Management bullet",
    "last_verified": "2026-10-30",
    "confidence": "High - read on the CMS FQHC News page; CoCM component codes per the CY 2026 Designated Care Management table; APCM add-ons also in the CY 2026 PFS final rule.",
    "id": "MED-025",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Care management (CCM/BHI/APCM)",
    "codes": "TCM + CCM/PCM etc.",
    "question": "Can an FQHC bill care management for a patient in the same period another provider bills it?",
    "answer": "Yes. Effective January 1, 2022, FQHCs may bill care management and TCM services (outside the PPS) for the same beneficiary during the same time period. Except TCM, care management is paid separately from the PPS, the face-to-face requirement is waived, and coinsurance applies as applicable.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§230",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-026",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Transitional care management",
    "codes": "99495, 99496",
    "question": "How does an FQHC bill transitional care management (TCM) to Medicare?",
    "answer": "TCM must be furnished within 30 days of discharge from a hospital (including observation or partial hospitalization), SNF or CMHC. Contact with the patient/caregiver must begin within 2 business days; the face-to-face visit must occur within 14 days (99495) or 7 days (99496). Bill the TCM code on the day of the face-to-face visit; only one TCM per beneficiary per 30-day post-discharge period. If it is the only medical service that day it is paid as a stand-alone visit; if on the same day as another visit, only one visit is paid.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§230.1",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-027",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Behavioral health / MFT & MHC",
    "codes": "G0469, G0470",
    "question": "Can marriage and family therapists (MFTs) and mental health counselors (MHCs) furnish FQHC visits under Medicare?",
    "answer": "Yes. MFTs and MHCs are FQHC practitioners. Each must hold a master's or doctor's degree qualifying for licensure in the state, have at least 2 years or 3,000 hours of post-degree supervised clinical experience, and be licensed or certified by the state. CSWs, MFTs and MHCs are covered only for the diagnosis and treatment of mental illness. Phone/electronic contacts are not separate visits unless billed as care management or virtual communication.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§150 (CP, CSW, MFT, MHC definitions and coverage)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-028",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Behavioral health / MFT & MHC",
    "codes": "Medication management",
    "question": "Is medication management on the same day as a medical visit a second (mental health) visit?",
    "answer": "No. Effective January 1, 2015, medication management is not a stand-alone FQHC visit. If furnished the same day as a qualifying medical visit, its charges go on that claim; if there is no qualifying visit, no claim is submitted and no payment is made.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Frequently Asked Questions on the Medicare FQHC PPS (Rev. 11-21-19; still posted on the CMS FQHC Center)",
    "source_url": "https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-faqs.pdf",
    "source_section": "Same-day visits Q3",
    "last_verified": "2026-10-30",
    "confidence": "High - read in the CMS FQHC PPS FAQ (Rev. 11-21-19), still linked on the CMS FQHC Center. Note the FAQ lists only CP/CSW as mental health practitioners; MFTs/MHCs were added later (BP13 §150).",
    "id": "MED-029",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Same-day visits / modifier 59 vs 25",
    "codes": "Modifier 59 (FQHC); 25 (RHC only)",
    "question": "What are all the exceptions to Medicare's one-visit-per-day rule for FQHCs, and is modifier 25 used?",
    "answer": "Encounters with more than one practitioner or multiple encounters the same day are one visit, except: (1) after the first visit the patient has an illness or injury needing more diagnosis/treatment - FQHCs use modifier 59 (RHCs may use 59 or 25); (2) a medical visit plus a mental health visit; (3) an IPPE plus another visit - this exception is listed for RHCs only; (4) an IOP service plus a medical visit. A mental health visit on the same day as IOP is paid only the IOP rate. These exceptions don't apply to grandfathered tribal FQHCs.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§40.3 (multiple visits on same day)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly. For FQHC PPS claims, the manual names modifier 59, not 25.",
    "id": "MED-030",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Claim form / type of bill",
    "codes": "All same-day services on one claim",
    "question": "If a patient is seen at two sites of the same FQHC on one day, are they on separate claims?",
    "answer": "No. All visits within the FQHC organization on the same day for the same patient go on one claim, even at different sites. The attending NPI (UB-04 FL 76) is the practitioner with overall responsibility for that day's care. G codes and qualifying visit codes are required on all FQHC claims, including MSP/secondary claims; the payment code does not have to be the first line.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Frequently Asked Questions on the Medicare FQHC PPS (Rev. 11-21-19; still posted on the CMS FQHC Center)",
    "source_url": "https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-faqs.pdf",
    "source_section": "Billing and Claims Processing Q1-Q7",
    "last_verified": "2026-10-30",
    "confidence": "High - CMS FQHC PPS FAQ (Rev. 11-21-19), still posted.",
    "id": "MED-031",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Rates / G-code charges",
    "codes": "G0466, G0467, G0468, G0469, G0470",
    "question": "How should an FQHC set the charge for its G codes?",
    "answer": "Each G code amount is the sum of the FQHC's normal charges for the typical bundle of services it furnishes to Medicare patients in that type of encounter. The G code charge must be uniform for all patients, and the individual service charges must match what the FQHC charges others. It may only change when the bundle or the charges in it change. Claim charges need not equal the G code amount. Keep the bundle list on file; provide it only on request.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Frequently Asked Questions on the Medicare FQHC PPS (Rev. 11-21-19; still posted on the CMS FQHC Center)",
    "source_url": "https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-faqs.pdf",
    "source_section": "Payment codes Q1-Q8",
    "last_verified": "2026-10-30",
    "confidence": "High - CMS FQHC PPS FAQ (Rev. 11-21-19), still posted.",
    "id": "MED-032",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Rates / PPS rate",
    "codes": "FQHC PPS base rate CY 2026: $207.72",
    "question": "What is the 2026 Medicare FQHC PPS base rate and how is it adjusted?",
    "answer": "From January 1 through December 31, 2026, the FQHC PPS base payment rate is $207.72, a 2.5% (FQHC market basket) increase over the 2025 rate of $202.65. It is adjusted by each FQHC's Geographic Adjustment Factor (GAF). The GAF applies only to the base rate, not to charges, and the claim uses the GAF in effect on the date of service. The PPS rate is also multiplied by 1.3416 for a new patient or a visit that includes an IPPE or AWV.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Transmittal R13506BP (CR 14309) - CY 2026 FQHC PPS and IOP rates (Dec 5, 2025)",
    "source_url": "https://www.cms.gov/files/document/r13506bp.pdf",
    "source_section": "Background (CY 2026 rate); GAF paragraph",
    "last_verified": "2026-10-30",
    "confidence": "High - read in CMS Transmittal R13506BP (Dec 5, 2025). GAF claim-date rule from CMS FQHC PPS FAQ; 1.3416 factor from Ch. 9 §30.2.",
    "id": "MED-033",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Group therapy / IOP",
    "codes": "IOP: rev 0905 (0519 for MA); condition code 92",
    "question": "What does Medicare pay an FQHC for intensive outpatient program (IOP) services in 2026?",
    "answer": "For IOP services on or after January 1, 2026: $319.38 per day for 3 or fewer services and $418.45 per day for 4 or more services. Payment is the lesser of the FQHC's actual charges or the applicable IOP rate. Grandfathered tribal FQHCs are paid the IHS outpatient per-visit rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Transmittal R13506BP (CR 14309) - CY 2026 FQHC PPS and IOP rates (Dec 5, 2025)",
    "source_url": "https://www.cms.gov/files/document/r13506bp.pdf",
    "source_section": "IOP payment rates paragraph",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-034",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Incident-to services and supplies",
    "codes": "Incident-to; Part B drugs",
    "question": "Are incident-to services, supplies and Part B drugs billable separately by an FQHC under Medicare?",
    "answer": "No. Services and supplies incident to a practitioner's service are included in the PPS; they must be furnished by FQHC employees or staff under direct contract under direct supervision (immediately available may be met by real-time audio-video virtual presence; general supervision for care coordination and, from January 1, 2024, for behavioral health). An incident-to service alone is not a billable visit. Part B drugs furnished incident to a visit are included in the PPS and cannot be billed separately; a drug the patient purchased is not covered. Incident-to services on a different day may go in that visit's charges if furnished within a medically appropriate timeframe.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§120.1-120.3",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Benefit Policy Ch. 13 Rev. 13600.",
    "id": "MED-035",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Incident-to services and supplies",
    "codes": "Technical components; lab",
    "question": "Which services are billed outside the FQHC claim?",
    "answer": "Technical components of diagnostic tests (e.g., the EKG tracing, X-ray technical component) and laboratory tests are not FQHC services; they are billed separately under the applicable Part B payment system (lab with HCPCS). Venipuncture is included in the visit. Ch. 9 also lists DME, ambulance, hospital-based services, group services and non-face-to-face services as non-covered under the FQHC benefit and billed separately.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§90; §70.5",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 Rev. 13803.",
    "id": "MED-036",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Preventive / IPPE / AWV",
    "codes": "G0108, 97802, 97803, G0270; rev 0521",
    "question": "Are DSMT and MNT separate visits for an FQHC under Medicare?",
    "answer": "DSMT and MNT furnished by qualified practitioners are qualifying visits billed under the medical payment codes (G0466/G0467). They are not paid separately when furnished on the same day as another FQHC visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§70.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 Rev. 13803.",
    "id": "MED-037",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Preventive / IPPE / AWV",
    "codes": "Coinsurance waived (USPSTF A/B)",
    "question": "How is coinsurance calculated when a Medicare FQHC claim has both preventive and non-preventive services?",
    "answer": "Coinsurance is 20% of the lesser of the FQHC's charge for the payment code or the PPS rate, but coinsurance is waived for the IPPE, AWV and USPSTF A/B preventive services. To apply the waiver, the FQHC must report the preventive services with line-item charges; coinsurance is then assessed only on the non-waived services. If a claim contains only waived preventive services, Medicare pays 100% of the lesser of charges or the PPS rate. There is no Part B deductible on FQHC services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§90; §220.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Benefit Policy Ch. 13.",
    "id": "MED-038",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Vaccines",
    "codes": "Pneumococcal, influenza, hepatitis B, COVID-19; M0201",
    "question": "How are Part B vaccines priced on an FQHC claim since July 1, 2025?",
    "answer": "Since July 1, 2025, Part B preventive vaccines (pneumococcal, influenza, hepatitis B, COVID-19) and their administration are reported on the claim at the time of service, require no visit, are paid separately if furnished on a visit day, and have no coinsurance or deductible. Vaccine product payment follows CMS's Part B vaccine pricing (95% of AWP), and administration follows the national vaccine administration fee schedule; M0201 is the in-home add-on. Payments are reconciled to 100% of reasonable cost on the annual cost report.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§70.3; Benefit Policy Ch. 13 §80.1",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 (Rev. 13547 section) and BP13 §80.1.",
    "id": "MED-039",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Cost report / bad debt",
    "codes": "Form CMS-224-14",
    "question": "Does an FQHC still have to file a Medicare cost report under PPS, and what does it settle?",
    "answer": "Yes. Every FQHC must file an annual cost report (Form CMS-224-14), even with no GME, bad debt or vaccine costs. Through the cost report FQHCs are paid for GME, bad debt, Part B vaccines and covered COVID-19 monoclonal antibody products and their administration, and vaccine claim payments are reconciled. FQHCs may claim unpaid coinsurance as bad debt (42 CFR 413.89) after reasonable collection efforts; coinsurance waived by statute or a sliding fee scale may not be claimed. FQHCs are not subject to RHC productivity standards.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§80.1; §80.3; §80.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-040",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Cost report / bad debt",
    "codes": "Consolidated cost report",
    "question": "Can a multi-site FQHC file one consolidated Medicare cost report?",
    "answer": "Yes, if the A/B MAC approves it in advance of the reporting period. Once consolidated reporting is elected, the FQHC may not go back to individual reports without the MAC's prior approval.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§80.2",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly. Note: Ch. 13 addresses consolidated cost reports; there is no FQHC 'consolidated billing' rule like SNF consolidated billing in these sources.",
    "id": "MED-041",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Charges, waivers and sliding fee",
    "codes": "Coinsurance waiver; sliding fee",
    "question": "Can an FQHC waive Medicare coinsurance or use a sliding fee scale?",
    "answer": "Charges to Medicare patients must be the same as charges to non-Medicare patients. FQHCs may waive collection of all or part of the copayment depending on the beneficiary's ability to pay. HRSA-approved FQHCs must have a sliding fee scale per statutory and HRSA requirements. Waived amounts cannot be claimed as bad debt.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§90.1; §90.2; §80.1",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-042",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Charges, waivers and sliding fee",
    "codes": "Commingling",
    "question": "Can FQHC practitioners bill Part B fee-for-service from the FQHC space during FQHC hours?",
    "answer": "No. Commingling (sharing FQHC space, staff, supplies or equipment with an onsite Part B or Medicaid FFS practice of the same practitioners) is prohibited. A service an FQHC practitioner furnishes at the FQHC during FQHC hours must be billed as an FQHC service and cannot be carved out of the cost report and billed to Part B.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Benefit Policy Manual, Ch. 13 - RHC and FQHC Services (Rev. 13600, 02-20-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf",
    "source_section": "§100",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MED-043",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Procedures without a visit",
    "codes": "ABN",
    "question": "Can an FQHC bill a stand-alone procedure (no qualifying visit) to Medicare?",
    "answer": "Except for certain preventive services, procedures are not separately billable. With a qualifying visit the same day, the procedure's charges go on the claim and payment is the lesser of total charges or the adjusted PPS rate. Without a qualifying visit, no claim is submitted and no payment is made; CMS's FAQ says an ABN can be given and the patient billed in that situation.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Frequently Asked Questions on the Medicare FQHC PPS (Rev. 11-21-19; still posted on the CMS FQHC Center)",
    "source_url": "https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-faqs.pdf",
    "source_section": "Billing and Claims Processing Q8-Q9",
    "last_verified": "2026-10-30",
    "confidence": "High - CMS FQHC PPS FAQ (Rev. 11-21-19), still posted; confirm ABN use against current ABN instructions.",
    "id": "MED-044",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Eligibility / MBI",
    "codes": "MBI",
    "question": "What Medicare ID goes on FQHC claims, and what if the patient is in Medicare Advantage?",
    "answer": "Claims must be submitted with the Medicare Beneficiary Identifier (MBI), with limited exceptions (e.g., appeals, some audits). The MBI is 11 characters, numbers and uppercase letters only, never using S, L, O, I, B or Z, and must be protected as personally identifiable information. Patients in a Medicare Advantage plan should use their MA plan card for services; they still need the MBI for some purposes.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS - Medicare Beneficiary Identifiers (MBIs) (page last modified 09/10/2024)",
    "source_url": "https://www.cms.gov/training-education/partner-outreach-resources/new-medicare-card/medical-beneficiary-identifiers-mbis",
    "source_section": "MBI exceptions; 'What do MBIs look like?'",
    "last_verified": "2026-10-30",
    "confidence": "High - read on the CMS MBI page (last modified 09/10/2024).",
    "id": "MED-045",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare)",
    "payer": "Medicare Part B (FQHC PPS)",
    "payer_type": "Medicare",
    "category": "Timely filing",
    "codes": "12 months from date of service",
    "question": "What is the Medicare timely filing limit for FQHC claims?",
    "answer": "Under 42 CFR 424.44, Medicare FFS claims must be filed no later than 12 months (1 calendar year) after the date of service. For institutional claims with span dates, the 'Through' date generally starts the period. Exceptions are listed in Ch. 1 §70.7. An FQHC claim cannot span two calendar years.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 1 - General Billing Requirements (Rev. 13725, 04-10-26)",
    "source_url": "https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c01.pdf",
    "source_section": "§70; §70.1; §70.7",
    "last_verified": "2026-10-30",
    "confidence": "High - read in Ch. 1 Rev. 13725; calendar-year rule from Ch. 9 §100.",
    "id": "MED-046",
    "region": "National",
    "state_abbr": "MED"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - law",
    "codes": "SSA §1857(e)(3); 42 U.S.C. 1395w-27(e)(3)",
    "question": "What federal law requires Medicare Advantage plans to pay FQHCs fairly and creates the wrap payment?",
    "answer": "SSA §1857(e)(3)(A) requires an MA organization's written agreement with an FQHC to pay at least what the plan would pay a non-FQHC provider for similar services. Under §1857(e)(3)(B), the FQHC must accept that plan payment plus the federal (wrap) payment under §1833(a)(3)(B) as payment in full, and may collect only the cost sharing allowed under the MA contract.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Social Security Act §1857(e)(3) / 42 U.S.C. 1395w-27(e)(3) - U.S. Code 2024 edition (GovInfo)",
    "source_url": "https://www.govinfo.gov/content/pkg/USCODE-2024-title42/pdf/USCODE-2024-title42-chap7-subchapXVIII-partC-sec1395w-27.pdf",
    "source_section": "42 U.S.C. 1395w-27(e)(3)(A)-(B)",
    "last_verified": "2026-10-30",
    "confidence": "High - read in the U.S. Code (2024 edition, GovInfo).",
    "id": "MA-001",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - law",
    "codes": "42 CFR 422.527",
    "question": "What does 42 CFR 422.527 require in an MA plan's contract with an FQHC?",
    "answer": "The MA organization must pay the FQHC an amount not less than it pays other providers for similar services. The FQHC must accept the MA payment plus CMS's supplemental payment as payment in full, except for allowable beneficiary cost sharing. Financial incentives (risk pools, bonuses, withholds) are not counted in the MA payment amount used to compute the supplemental payment.",
    "claim_format": "UB-04 / 837I",
    "source_title": "42 CFR 422.527 - Agreements with FQHCs (eCFR, current)",
    "source_url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-K/section-422.527",
    "source_section": "§422.527(a)-(c)",
    "last_verified": "2026-10-30",
    "confidence": "High - read in eCFR (current).",
    "id": "MA-002",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - law",
    "codes": "42 CFR 422.316",
    "question": "Who pays the FQHC wrap for MA patients, and how often?",
    "answer": "CMS (through the MAC), not the MA plan, pays the FQHC directly, at least quarterly. The amount is the §1833(a)(3)(B) amount minus the MA plan's payment, including contracted cost sharing. CMS does not reduce its monthly payments to the MA plan for this.",
    "claim_format": "UB-04 / 837I",
    "source_title": "42 CFR 422.316 - Special rules for payments to FQHCs (eCFR, current)",
    "source_url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-G/section-422.316",
    "source_section": "§422.316(a)-(b)",
    "last_verified": "2026-10-30",
    "confidence": "High - read in eCFR (current).",
    "id": "MA-003",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - law",
    "codes": "42 CFR 405.2469",
    "question": "How does 42 CFR 405.2469 define the FQHC supplemental payment for MA enrollees?",
    "answer": "An FQHC under contract with an MA organization is eligible for a supplemental payment covering the difference between what it is paid by the MA plan (including cost sharing) and what it would get under the FQHC PPS (or the IHS rate for grandfathered tribal FQHCs, or the §405.2462(j) rate). Financial incentives such as risk pools, bonuses and withholds are excluded. The payment is made per visit for covered services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "42 CFR 405.2469 - FQHC supplemental payments (eCFR, current)",
    "source_url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-X/section-405.2469",
    "source_section": "§405.2469(a)-(c)",
    "last_verified": "2026-10-30",
    "confidence": "High - read in eCFR (current).",
    "id": "MA-004",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - law",
    "codes": "42 CFR 405.2469(d); mental health telecom",
    "question": "Do MA mental health visits by telecommunications qualify for the wrap?",
    "answer": "42 CFR 405.2469(d) bases the supplemental payment on visits that are face-to-face or mental health visits furnished through interactive telecommunications. The regulation text shows an in-person requirement 'on or after October 1, 2025' for telecom mental health visits, but CMS's current FQHC guidance says the in-person requirement does not take effect until after January 1, 2028.",
    "claim_format": "UB-04 / 837I",
    "source_title": "42 CFR 405.2469 - FQHC supplemental payments (eCFR, current)",
    "source_url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-X/section-405.2469",
    "source_section": "§405.2469(d)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the eCFR date conflicts with CMS's 10/29/2026 FQHC News page and 10-09-2026 Telehealth FAQ (in-person requirement after 1/1/2028); confirm with your MAC.",
    "id": "MA-005",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - claims",
    "codes": "TOB 77X; rev 0519; G0466-G0470 + qualifying visit",
    "question": "How do I bill the Medicare Advantage wrap claim to the MAC?",
    "answer": "Bill the MAC (not the MA plan) on TOB 77X with revenue code 0519. Under the PPS, report the FQHC payment code and the qualifying visit both on 0519 lines (e.g., 0519 G0467 plus 0519 with the visit code). Do not report revenue codes 052X or 0900 on the same claim as 0519. Ch. 9 gives the billed amount as 'FQHC interim all-inclusive rate - estimated average payment from the MA plan plus any beneficiary cost sharing', which must be greater than 0. The MAC pays the interim supplemental rate for each qualified visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 (§60.4, Rev. 13264).",
    "id": "MA-006",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - claims",
    "codes": "Rev 0519",
    "question": "Which MA visits qualify for the FQHC supplemental payment?",
    "answer": "Ch. 9 §60.4 limits the supplemental payment to face-to-face visits with a physician, NP, PA, certified nurse-midwife, clinical psychologist, clinical social worker, or a qualified DSMT/MNT provider.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly. Note: §60.4 has not been updated to list MFTs/MHCs, though they became FQHC practitioners in 2024 (BP13 §150); ask your MAC.",
    "id": "MA-007",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - calculation",
    "codes": "0519; PPS rate vs MA contract rate",
    "question": "How is the MA wrap amount calculated?",
    "answer": "The wrap is based on the PPS rate, with no comparison to the FQHC's charges, and is not adjusted for coinsurance or preventive services. If the MA contract rate is less than the PPS rate, Medicare pays the difference. CMS example: PPS rate $225 - MA contract rate $200 = $25 wrap; if the MA contract rate were $250, no wrap is paid. The G0468 charge ($170 in the example) is not used in the calculation.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.5",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 §60.5.",
    "id": "MA-008",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - calculation",
    "codes": "Cost sharing",
    "question": "Does the Part B deductible or 20% coinsurance apply to the MA wrap claim?",
    "answer": "No. No deductible applies and the 20% Medicare coinsurance is not applied to MA supplemental claims. The MA plan's cost sharing is part of the calculation (the wrap covers the PPS rate minus the MA payment including cost sharing), and the FQHC may collect only the MA plan's allowed cost sharing from the patient.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.4; 42 CFR 422.527(b); 42 CFR 422.316",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 and eCFR.",
    "id": "MA-009",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - calculation",
    "codes": "Interim rate; cost report",
    "question": "How are MA wrap payments reconciled?",
    "answer": "Before cost report data exists, the FQHC gives the MAC a documented estimate of its average per-visit payment from each MA plan, and the MAC sets an interim supplemental rate for each plan. The FQHC reports actual MA revenue and visits on its Medicare cost report; interim payments are reconciled at cost report settlement, and the final rate becomes the next year's interim rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 §60.4.",
    "id": "MA-010",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - claims",
    "codes": "CWF / RTP",
    "question": "Why would an MA wrap claim be returned?",
    "answer": "Medicare's Common Working File checks that the patient was enrolled in an MA plan on the date of service. Claims for patients not enrolled in MA are rejected and returned to the provider. The billed amount must also be greater than zero.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§60.4",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 §60.4.",
    "id": "MA-011",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Medicare Advantage wrap - claims",
    "codes": "G0466-G0470; detailed HCPCS",
    "question": "Are FQHC G codes required on MA wrap claims, and when is the wrap paid?",
    "answer": "Yes. MA wrap claims need the FQHC payment codes and the detailed HCPCS coding required on all FQHC PPS claims. The supplemental payment is made only if the MA contract rate is less than the adjusted PPS rate, and the payment is the difference minus cost sharing the patient owes.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Frequently Asked Questions on the Medicare FQHC PPS (Rev. 11-21-19; still posted on the CMS FQHC Center)",
    "source_url": "https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-faqs.pdf",
    "source_section": "Medicare Secondary Payer / MA Q10-Q11",
    "last_verified": "2026-10-30",
    "confidence": "High - CMS FQHC PPS FAQ (Rev. 11-21-19), still posted on the CMS FQHC Center.",
    "id": "MA-012",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Group therapy / IOP",
    "codes": "IOP; rev 0519; condition code 92",
    "question": "How is IOP billed for a Medicare Advantage patient at an FQHC?",
    "answer": "IOP claims (TOB 77X, condition code 92) use revenue code 0905, or 0519 for an MA claim, with at least one IOP primary-service code. A payment code and qualifying visit are not required with an IOP visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 9 - Rural Health Clinics/Federally Qualified Health Centers (Rev. 13803, 05-28-26)",
    "source_url": "https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf",
    "source_section": "§110",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in Ch. 9 §110.",
    "id": "MA-013",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Original Medicare supplemental (wrap) payment via the A/B MAC",
    "payer_type": "Medicare Advantage",
    "category": "Timely filing",
    "codes": "12 months (Medicare FFS rule)",
    "question": "What is the filing limit for the MA wrap claim to the MAC?",
    "answer": "Ch. 9 §60.4-60.5 does not state a separate wrap deadline. Wrap claims are Medicare FFS claims to the MAC, and the general Medicare FFS rule (42 CFR 424.44) is 12 months (1 calendar year) after the date of service.",
    "claim_format": "UB-04 / 837I",
    "source_title": "CMS Medicare Claims Processing Manual, Ch. 1 - General Billing Requirements (Rev. 13725, 04-10-26)",
    "source_url": "https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c01.pdf",
    "source_section": "§70",
    "last_verified": "2026-10-30",
    "confidence": "Medium - applying the general Medicare FFS rule to wrap claims is an inference; the MA plan's own claim has its own deadline (see plan entries). Confirm with your MAC.",
    "id": "MA-014",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "UnitedHealthcare Medicare Advantage",
    "payer_type": "Medicare Advantage",
    "category": "Preventive / IPPE / AWV",
    "codes": "G0468 with G0402, G0438, G0439",
    "question": "How does UnitedHealthcare Medicare Advantage handle IPPE/AWV in an FQHC?",
    "answer": "UHC's 2026 MA preventive guide says an IPPE or AWV performed in an FQHC is payable under the FQHC PPS, and G0468 must be accompanied by a qualifying visit code (G0402, G0438 or G0439). Not all FQHCs are contracted as an FQHC with UHC - check your UHC contract.",
    "claim_format": "UB-04 / 837I",
    "source_title": "UnitedHealthcare Medicare Advantage - 2026 Preventive Screening Guidelines (coding quick reference)",
    "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/medicare/MA-Preventive-Services-Coding-Guidelines.pdf",
    "source_section": "Annual wellness visit / Welcome to Medicare table footnote '*FQHC'",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MA-015",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "UnitedHealthcare Medicare Advantage",
    "payer_type": "Medicare Advantage",
    "category": "Telehealth (non-mental health)",
    "codes": "POS 02, 10 (professional)",
    "question": "Does UnitedHealthcare Medicare Advantage recognize an FQHC as a telehealth originating site?",
    "answer": "Yes. UHC's MA telehealth reimbursement policy lists an FQHC among CMS-designated originating sites it recognizes, and requires telehealth to be reported with POS 02 or 10 on professional claims.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "UnitedHealthcare Medicare Advantage Reimbursement Policy 2026R9039A - Telehealth and Telemedicine Policy, Professional",
    "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/MEDADV-Telehealth-and-Telemedicine-Policy.pdf",
    "source_section": "Originating Site Requirements; POS section",
    "last_verified": "2026-10-30",
    "confidence": "Medium - this is a professional (CMS-1500) policy and has no FQHC PPS-specific instructions; check your UHC FQHC contract for how FQHC telehealth is paid.",
    "id": "MA-016",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Humana Medicare Advantage",
    "payer_type": "Medicare Advantage",
    "category": "Timely filing",
    "codes": "1 year from date of service",
    "question": "What is Humana's timely filing limit for Medicare Advantage claims?",
    "answer": "Unless the provider agreement or law says otherwise, Humana's 2026 provider manual sets the claim submission time frame for Medicare lines of business at 1 year from the date of service. Paper claims must use original CMS-1500/UB-04 forms; Humana charges a fee for paper claims.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Humana 2026 Provider Manual for physicians, hospitals and healthcare providers",
    "source_url": "https://assets.humana.com/is/content/humana/FINAL_773902ALL0725-A_2026_ProviderManual-Delegated_formattedpdf",
    "source_section": "Claims submission - time frame for submitting claims",
    "last_verified": "2026-10-30",
    "confidence": "High - read in the Humana 2026 Provider Manual. The manual has no FQHC-specific billing section.",
    "id": "MA-017",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Humana Medicare Advantage",
    "payer_type": "Medicare Advantage",
    "category": "Patient billing / cost share",
    "codes": "Balance billing; cost-share protected members",
    "question": "What can an FQHC collect from a Humana Medicare Advantage member?",
    "answer": "Providers must accept Humana's payment as payment in full for covered services and may collect only the member's copayment, coinsurance and deductible. For an MA member, a provider may collect for a non-covered service only if it followed Humana's utilization management/preauthorization procedures. Cost-share protected members (identified by RARCs on the remittance) must not be charged cost sharing.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Humana 2026 Provider Manual for physicians, hospitals and healthcare providers",
    "source_url": "https://assets.humana.com/is/content/humana/FINAL_773902ALL0725-A_2026_ProviderManual-Delegated_formattedpdf",
    "source_section": "Balance Billing; Cost-Share Protected Members",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MA-018",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Aetna Medicare Advantage",
    "payer_type": "Medicare Advantage",
    "category": "Patient billing / cost share",
    "codes": "ABN not valid; organization determination",
    "question": "Can an FQHC use an ABN or bill an Aetna Medicare Advantage member for a non-covered service?",
    "answer": "Aetna says an ABN is not a valid denial notice for MA members (CMS prohibits it). MA plans must cover everything Original Medicare covers. A member can be charged for a non-covered service only if there was a pre-service organization determination (OD) denial; otherwise hold the member harmless and charge only normal copays. Services never covered by Medicare or clearly excluded in the Evidence of Coverage don't need an OD; medical-necessity denials are not 'clear exclusions'. Aetna asks providers to bill it the same way they bill traditional Medicare.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Aetna OfficeLink Updates, June 2026",
    "source_url": "https://www.aetna.com/content/dam/aetna/pdfs/olu/officelink-updates-june-2026-olu.pdf",
    "source_section": "Advance Beneficiary Notice of Noncoverage (ABN) documents; Medicare Advantage - billing",
    "last_verified": "2026-10-30",
    "confidence": "High - read in Aetna OfficeLink Updates (June 2026). Not FQHC-specific.",
    "id": "MA-019",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Wellcare By Superior HealthPlan (Texas D-SNP)",
    "payer_type": "Medicare Advantage",
    "category": "Claim form / type of bill",
    "codes": "UB-04; group NPI; BH modifier",
    "question": "How does Wellcare By Superior (Texas D-SNP) want FQHCs to bill?",
    "answer": "FQHC/RHC claims must use the group NPI, behavioral health claims must carry the appropriate BH modifier, and all claims must be on a UB-04. Medicare-primary claims are paid at the CMS Federal Encounter Rate or fee schedule based on the services; Medicaid-primary claims use the Texas Medicaid fee schedule. Timely filing is 95 days from the date the service was performed (or as specified in the provider contract); corrected claims and reconsiderations must be received within 120 days of the original EOP.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wellcare By Superior HealthPlan (Texas D-SNP) Provider Manual 2026",
    "source_url": "https://www.superiorhealthplan.com/content/dam/centene/Superior/Provider/PDFs/TX_WBSHP_DSNP_26ProvMan_Final_508c.pdf",
    "source_section": "FQHC/RHC/ERC section (p. 75); Timely Filing; Corrected Claims",
    "last_verified": "2026-10-30",
    "confidence": "High - read in the 2026 Wellcare By Superior D-SNP Provider Manual.",
    "id": "MA-020",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Wellcare Meridian Dual Align (Illinois HMO D-SNP)",
    "payer_type": "Medicare Advantage",
    "category": "Claim form / type of bill",
    "codes": "T1015 (do not bill); CMS-1500 (do not use)",
    "question": "How should Illinois FQHCs bill Wellcare Meridian Dual Align (D-SNP) members?",
    "answer": "Follow Medicare (CMS) FQHC billing rules per Claims Manual Ch. 9. Do not bill T1015 or use the CMS-1500; claims billed on a CMS-1500 with T1015 deny as EXF2 'DUALS MEMBER - follow Medicare submission guidelines' (CARC 252/RARC N479).",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wellcare Meridian Dual Align (HMO D-SNP, Illinois) - FQHC/RHC billing reminder (04/14/26)",
    "source_url": "https://www.ilmeridian.com/newsroom/wellcare-meridian-dual-align--hmo-d-snp--billing-requirements-re.html",
    "source_section": "Newsroom notice dated 04/14/26",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MA-021",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "All states (Medicare Advantage)",
    "payer": "Anthem Blue Cross and Blue Shield Medicare Advantage",
    "payer_type": "Medicare Advantage",
    "category": "Credentialing / claims disputes",
    "codes": "CMS certification; 365 days; 120 days",
    "question": "What does Anthem's Medicare Advantage guidebook require of FQHCs and for corrected claims?",
    "answer": "FQHCs are credentialed as facilities requiring CMS certification. Corrected claims (for claims originally filed timely) must be received within 365 days of the date of service. Claim payment reconsiderations are accepted within 120 calendar days of the EOP date. Anthem will reconsider a timely-filing denial if you prove the claim was filed timely or show good cause.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Anthem Blue Cross and Blue Shield Medicare Advantage Provider Guidebook (effective Jan 1, 2027; dated Nov 1, 2026)",
    "source_url": "https://www.anthembluecross.com/content/dam/digital/docs/provider/commercial/manuals/ABSCRPM-0010-20.pdf",
    "source_section": "Ch. 3 credentialing - HDO types requiring CMS certification; §5.2 (timely filing disputes); §5.3 reconsideration; corrected-claim submission table (Ch. 5)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the guidebook is effective January 1, 2027 (dated Nov 1, 2026) and has no FQHC billing section; verify the version in effect for your date of service.",
    "id": "MA-022",
    "region": "National",
    "state_abbr": "MA"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "CPT/HCPCS E/M (e.g., 99202-99215); POS 50",
    "question": "How do I get reimbursed for office visits for Kansas Medicaid (fee-for-service)?",
    "answer": "Bill KMAP on the CMS-1500 (or 837P) under the FQHC provider number with the CPT/HCPCS code for the visit (for example, an E/M code) and place of service 50. A covered visit is a face-to-face encounter with a qualifying practitioner (physician, PA, APRN, nurse midwife, dentist, clinical psychologist, clinical social worker and others listed). KMAP pays the center's PPS encounter rate, generally once per day. A same-day visit for a different illness or injury counts as a second visit if documented: use modifier 25, or 76 then 25 for the same code.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§7000 (PDF p.4); §8400 Visit or Encounter, Place-of-Service (PDF p.7-8); Reimbursement (PDF p.20-21)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-019",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KanCare MCOs (Healthy Blue, Sunflower, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Office visits / encounter payment",
    "codes": "POS 50; encounter codes",
    "question": "How do I get reimbursed for office visits for Kansas managed Medicaid (KanCare MCOs)?",
    "answer": "The state requires KanCare MCOs to reimburse FQHCs using the PPS rate. Bill the MCO on the CMS-1500/837P with the same visit and place-of-service rules as KMAP fee-for-service (POS 50; modifier 25 or 76+25 for a documented same-day second visit). Every claim needs the rendering provider's NPI, and that provider must be enrolled in KMAP. Plan specifics: UnitedHealthcare requires the CMS-1500 for FQHCs; Sunflower says to bill POS 50 with the appropriate encounter codes.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 'Managed Care Entity Contracts' (PDF p.21); KanCare All-MCO FQHC/RHC Training Q2-2026 (p.3, 13); UHC KS manual, Acceptable claim forms (PDF p.77); Sunflower manual billing tips (PDF p.117)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-020",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "CMS-1500 / 837P",
    "question": "What claim form does a Kansas FQHC use for KMAP, and where does it go?",
    "answer": "KMAP requires the CMS-1500 paper claim or its electronic equivalent. Submit through the KMAP secure website, Provider Electronic Solutions (PES), or on paper (original red form) to the KMAP Office of the Fiscal Agent, PO Box 3571, Topeka, KS 66601-3571. Sending a KanCare paper claim to KMAP can cause denial.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§7000 (PDF p.4)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-021",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Qualifying visit / practitioners",
    "codes": "Modifier TD (RN EPSDT screen)",
    "question": "Who counts as a billable FQHC practitioner in Kansas Medicaid?",
    "answer": "Physician, PA, APRN, nurse midwife, dentist (FQHC only), clinical psychologist, clinical social worker, a visiting nurse, an RN performing a KBH-EPSDT nursing assessment (modifier TD), and an RDH with extended care permit (FQHC only). No exam means no visit, e.g., a prescription-renewal-only contact. The KanCare MCO training also lists LCMFT and LCPC.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Visit or Encounter (PDF p.7-8); KanCare All-MCO Training (p.3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-022",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "Modifiers 25, 76",
    "question": "Can I bill two visits on the same day in Kansas Medicaid?",
    "answer": "Generally multiple encounters on the same day count as one visit. If after the first visit the patient has an illness or injury needing different diagnosis and treatment, the second visit counts. It must be medically necessary and document why it couldn't happen at the first visit. Use modifier 25 for a different procedure code, or modifier 76 followed by 25 for the same code.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 More Than One Encounter on the Same Day (PDF p.8)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-023",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Place of service",
    "codes": "POS 50, 72, 31, 12, 13, 15; POS 11 not accepted",
    "question": "What place-of-service code does a Kansas FQHC use?",
    "answer": "FQHCs use POS 50 (RHCs use 72); POS 11 is no longer accepted for FQHC services. Services outside the center use the actual setting (e.g., SNF 31, home 12, assisted living 13, mobile unit 15 from 2/1/2023 for an allowed code list). Technical components of radiology/EKG and lab, billed under the performing provider, use POS 11.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Place-of-Service Criteria (PDF p.8-9)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-024",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "T1015 / encounter code",
    "codes": "T1015 (not referenced)",
    "question": "Does Kansas Medicaid require T1015 for FQHC encounters?",
    "answer": "The KMAP RHC/FQHC manual does not mention T1015. It instructs billing the CPT/HCPCS service codes with POS 50 on the CMS-1500. Sunflower's manual says to bill 'appropriate encounter codes' without naming them; ask the MCO which code(s) it expects.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "Full manual searched; §7000, §8400",
    "last_verified": "2026-10-30",
    "confidence": "Not verified - this is an absence in the source; no Kansas source read says T1015 is required or prohibited.",
    "id": "KS-025",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Bundling / incident-to",
    "codes": "VFC vaccines; drugs; EKG/radiology professional component",
    "question": "What is included in the Kansas FQHC encounter rate (not separately billable)?",
    "answer": "Services that are part of the visit are not separately billable: incident-to services, the professional component of radiology and EKG by a center practitioner, drugs and biologicals that are not usually self-administered, and vaccine/injection administration. KMAP asks that VFC vaccines be billed for data collection even though they are not paid. Procedures are included in the visit; global surgical billing does not apply.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Content of Service",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-026",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate setting",
    "codes": "BIPA PPS; MEI",
    "question": "How is a Kansas FQHC's Medicaid PPS rate set and updated?",
    "answer": "Kansas uses the BIPA PPS rate derived from the center's base years, with no retroactive settlement. The rate changes each October 1 by the Medicare Economic Index (MEI) for primary care. Initial rates: centers already established before Medicaid enrollment use finalized Medicare cost reports for the two most recent years; newly certified centers get the average rate of similar centers in the area. For a change in scope, submit a written description with the budgeted cost change and visit counts. PPS rates will be re-evaluated at least every five years.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Reimbursement / PPS Baseline Rate / Rate Change (PDF p.20-21)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-027",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "Cost report; dentist productivity 2,100",
    "question": "When are Kansas Medicaid FQHC cost reports due?",
    "answer": "Each FQHC submits the same cost report filed with Medicare within five months after fiscal year end, with the supplemental items listed (trial balance, auditor's report, revenue list). Dentist visits and KBH-EPSDT nursing assessments differ from Medicare; use a productivity standard of 2,100 for dentist visits.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Cost Reports (PDF p.21)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-028",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Copays",
    "codes": "Copayment",
    "question": "Do Kansas Medicaid FFS patients owe a copay at an FQHC?",
    "answer": "No. KMAP eliminated fee-for-service copayments effective 1/1/2024.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8100 Copayment",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-029",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "LARC",
    "codes": "J7296, J7297, J7298, J7300, J7301, J7307",
    "question": "How are long-acting reversible contraceptives billed by a Kansas FQHC?",
    "answer": "LARC devices (J7297, J7301, J7298, J7296, J7307, J7300) are carved out of PPS. Bill them under the individual provider NPI at FFS rates with POS 11. The insertion is billed under the FQHC number and paid at the encounter rate.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 LARC (PDF p.14)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-030",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "ADA/CDT codes; fluoride",
    "question": "How does a Kansas FQHC bill dental services and fluoride?",
    "answer": "FQHCs bill dental services on the dental claim form using ADA procedure codes (see the KMAP Dental manual for coverage). In RHCs and FQHCs without a dental clinic, physicians, NPs and PAs may apply topical fluoride for Title XIX/XXI children, limited to three applications per member per calendar year, and only during a billable encounter.",
    "claim_format": "ADA dental claim",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Dental Services; Fluoride Applications",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-031",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Collaborative care (CoCM)",
    "codes": "CoCM codes",
    "question": "Can a Kansas FQHC bill collaborative care management under the FQHC NPI?",
    "answer": "No. Collaborative care codes must be billed under the professional (individual) NPI; they deny when billed under the FQHC NPI.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Collaborative Care (PDF p.13)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-032",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health",
    "codes": "Psychotherapy; MediKan",
    "question": "Are there behavioral health limits for MediKan patients at a Kansas FQHC?",
    "answer": "Yes. For the MediKan benefit plan, psychotherapy is limited to a maximum of 24 hours per calendar year.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8300 Benefit Plan",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-033",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Screenings",
    "codes": "96160, 96161, G8431, G8510",
    "question": "Can a Kansas FQHC bill maternal depression screening separately?",
    "answer": "No. Maternal depression screening (96160, 96161, G8431, G8510) is included in the encounter and is not paid on its own.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Maternal Depression Screening",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-034",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Hospice",
    "codes": "Modifier GV",
    "question": "How does a Kansas FQHC bill hospice attending physician services?",
    "answer": "Report modifier GV (attending physician not employed or paid by the hospice) on the claim line each day a hospice attending physician service is furnished. Claims without GV are denied, and so are GV claims for a non-hospice member.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Hospice",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-035",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Vision / optometry",
    "codes": "92002, 92004, 92012, 92014; POS 50/72",
    "question": "Are optometry exams paid at the PPS rate in Kansas?",
    "answer": "Yes. 92002, 92004, 92012 and 92014 billed with POS 50 (FQHC) or 72 (RHC) are paid at the PPS rate.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Optometry",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-036",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services away from center / hospital",
    "codes": "Individual provider number",
    "question": "Can a Kansas FQHC bill visits done outside the center or in the hospital?",
    "answer": "Visits away from the center by a practitioner compensated by the center are billed as FQHC visits; if the center does not compensate the practitioner, bill under the individual provider number. Hospital, ER and swing-bed services are not FQHC services.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Services Away from the Center",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-037",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KMAP (KanCare fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "POS 02, POS 10; Q3014; 90791-90853, 99202-99215",
    "question": "How does a Kansas FQHC bill telemedicine to KMAP?",
    "answer": "The RHC/FQHC manual refers to General Benefits §2720. That section says the distant site bills the listed code with POS 02 (not the patient's home) or POS 10 (home); the GT modifier is no longer used. Payment matches face-to-face, and the originating site may bill Q3014. Verbal consent is required, then written. Code lists show which codes allow audio-only (for example, 90791-90853 and 99202-99215).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP General Benefits Fee-for-Service Provider Manual (updated 12.2025; official KMAP copy)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/GenBenefits_25302_25297_25296_25279.pdf",
    "source_section": "General Benefits §2720 Telemedicine (updated 05/25), p. 2-28 and code lists",
    "last_verified": "2026-10-30",
    "confidence": "High - re-read 2026-10-30 in the official KMAP copy (manual updated 12.2025).",
    "id": "KS-038",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KanCare MCOs (Healthy Blue, Sunflower, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Enrollment / rendering NPI",
    "codes": "Rendering NPI; KMAP enrollment",
    "question": "Do individual FQHC practitioners need to be enrolled to bill KanCare MCOs?",
    "answer": "Yes. Since 7/1/2019 all performing providers must be enrolled in KMAP. The facility enrolls as the FQHC type and practitioners/groups enroll separately, and every claim needs the rendering provider's NPI (per KMAP bulletin 19088 as cited in the training).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KanCare All MCO Training for FQHC/RHCs, Q2-2026 (State approved 03/23/26)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Training%20Materials/KanCare_All_MCO_RHC-FQHC_Training_Q2-2026_StateApproved032326.pdf",
    "source_section": "Enrollment slides",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-039",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KanCare MCOs (Healthy Blue, Sunflower, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Secondary claims / other insurance",
    "codes": "CMS-1500",
    "question": "How do KanCare MCOs pay an FQHC when another insurer pays first?",
    "answer": "Bill the primary first, then the MCO on the CMS-1500 (or electronic equivalent). MCOs use the same pricing logic as secondary payer: the claim is allowed up to the state-determined encounter rate, and the MCO pays that rate minus the primary payment. Healthy Blue's manual also says FQHC claims (including Medicare crossovers) are exempt from its other-insurance pricing algorithm and pay the Medicaid allowed amount minus the other payment.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KanCare All MCO Training for FQHC/RHCs, Q2-2026 (State approved 03/23/26)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Training%20Materials/KanCare_All_MCO_RHC-FQHC_Training_Q2-2026_StateApproved032326.pdf",
    "source_section": "Secondary Claims (p.13); Healthy Blue KS manual (PDF p.33)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-040",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KanCare MCOs (Healthy Blue, Sunflower, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Wraparound",
    "codes": "None documented",
    "question": "Is there a separate Kansas Medicaid wraparound payment for MCO claims?",
    "answer": "No separate Kansas wraparound process was found in the sources read. The KMAP manual says MCOs must reimburse at the PPS rate, and the state training says MCOs pay up to the state-set encounter rate.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KMAP RHC/FQHC Fee-for-Service Provider Manual (updated 01.2025)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Provider%20Manuals/RHC_FQHC_24280_24023.pdf",
    "source_section": "§8400 Managed Care Entity Contracts (PDF p.21)",
    "last_verified": "2026-10-30",
    "confidence": "Not verified - absence in the sources read; ask KDHE/KMAP if you expect a reconciliation.",
    "id": "KS-041",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KanCare MCOs (Healthy Blue, Sunflower, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / contacts",
    "codes": "Healthy Blue; Sunflower; UnitedHealthcare",
    "question": "Which MCOs cover KanCare in 2026, and where are their FQHC resources?",
    "answer": "The Q2-2026 state-approved all-MCO training covers Healthy Blue, Sunflower Health Plan and UnitedHealthcare Community Plan. Provider services numbers in the plan manuals: Healthy Blue 833-838-2595; Sunflower 1-877-644-4623; UnitedHealthcare 1-877-542-9235.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KanCare All MCO Training for FQHC/RHCs, Q2-2026 (State approved 03/23/26)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Training%20Materials/KanCare_All_MCO_RHC-FQHC_Training_Q2-2026_StateApproved032326.pdf",
    "source_section": "MCO resource slides; plan manuals",
    "last_verified": "2026-10-30",
    "confidence": "Medium - Aetna Better Health of Kansas is not in the 2026 training; we did not find a state notice confirming its exit.",
    "id": "KS-042",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "UnitedHealthcare Community Plan (KanCare)",
    "payer_type": "Managed Medicaid",
    "category": "Claim form / submission",
    "codes": "Payer ID 96385; CMS-1500",
    "question": "How do I submit FQHC claims to UnitedHealthcare KanCare?",
    "answer": "UHC's 2026 KanCare manual says to use the CMS-1500 for RHCs/FQHCs. Payer ID 96385 appears on the sample member ID cards. Paper claims go to UnitedHealthcare Community Plan, P.O. Box 5270, Kingston, NY 12402-5270; claims line 1-877-542-9235. Participating providers must have a KMAP ID to be paid. The manual has no FQHC-specific encounter-rate or wrap detail.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "UnitedHealthcare Community Plan of Kansas (KanCare) 2026 Care Provider Manual",
    "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/comm-plan/KS-AdminGuide.pdf",
    "source_section": "Claims chapter - Acceptable claim forms & Payment requirements (PDF p.76-77); contacts table; ID card samples (PDF p.74-75)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-043",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "Sunflower Health Plan",
    "payer_type": "Managed Medicaid",
    "category": "Claim form / timely filing",
    "codes": "POS 50; encounter codes",
    "question": "What are Sunflower's FQHC billing tips and timely filing limit?",
    "answer": "Sunflower's billing tips for FQHC/RHC: bill the correct place of service (50 FQHC; 72 RHC) and appropriate encounter codes. Timely filing is 180 calendar days from the date of service.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Sunflower Health Plan Provider Manual (July 29, 2026)",
    "source_url": "https://www.sunflowerhealthplan.com/content/dam/centene/sunflower/pdfs/Sunflower_ProviderManual_July_2026.pdf",
    "source_section": "FQHC/RHC billing tips (PDF p.117); timely filing (PDF p.53)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-044",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "Healthy Blue (KanCare)",
    "payer_type": "Managed Medicaid",
    "category": "Claim form / timely filing",
    "codes": "Timely filing",
    "question": "What is Healthy Blue Kansas's timely filing limit for FQHC claims?",
    "answer": "Generally 180 days for initial claims; corrected claims within 365 days. Provider services 833-838-2595.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Healthy Blue Kansas Medicaid (KanCare) Provider Manual (June 2026)",
    "source_url": "https://www.healthybluekansas.com/content/dam/digital/healthyblue/documents/provider/ks/general/KSHB-CD-PM-061368-24-EXPRESS-KanCare.pdf",
    "source_section": "Claims sections",
    "last_verified": "2026-10-30",
    "confidence": "Medium - summarized from manual; confirm exceptions in the claims chapter.",
    "id": "KS-045",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Kansas",
    "payer": "KanCare MCOs (Healthy Blue, Sunflower, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Community health workers",
    "codes": "CHW codes",
    "question": "How are community health worker services billed by a Kansas FQHC?",
    "answer": "CHW services are billed under a non-FQHC NPI at FFS rates (KMAP bulletin 23343 as cited in the state training).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "KanCare All MCO Training for FQHC/RHCs, Q2-2026 (State approved 03/23/26)",
    "source_url": "https://portal.kmap-state-ks.us/Documents/Provider/Training%20Materials/KanCare_All_MCO_RHC-FQHC_Training_Q2-2026_StateApproved032326.pdf",
    "source_section": "CHW slide (p.18)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "KS-046",
    "region": "Region 7",
    "state_abbr": "KS"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "T1015 + modifier AH, AJ, AM, SA, TD, TE, TH, U1, U2, or U7",
    "question": "How do I get reimbursed for office visits for Texas Medicaid (fee-for-service)?",
    "answer": "Bill all services in the encounter under procedure code T1015, with a modifier showing the primary practitioner (AH, AJ, AM, SA, TD, TE, U1, U2, U7; TH added for antepartum/postpartum). Exceptions with their own codes are family planning, THSteps medical/dental, copayments, vision, mental health and certain case management. Fold incidental services into the encounter charge (TMHP's example: a $30 visit plus a $15 lab is billed as T1015 for $45). The center is paid its encounter rate.",
    "claim_format": "Approved electronic format, UB-04 CMS-1450 or CMS-1500",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1.2 (p.10); §4.3.1 Claims Information (p.14)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-047",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "UB-04 CMS-1450; CMS-1500; 2017 Claim Form; ADA",
    "question": "What claim form does a Texas FQHC use for Medicaid?",
    "answer": "Medicaid-only FQHC services go to TMHP in an approved electronic format or on a UB-04 CMS-1450, CMS-1500, or 2017 paper claim form. THSteps dental uses the ADA form; family planning for HHSC-contracted FQHCs uses the 2017 Claim Form. For a client with both Medicare and Medicaid, file on the same claim form used for Medicare. TMHP does not supply forms and does not key data from attachments.",
    "claim_format": "UB-04/CMS-1500/2017/ADA",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.3.1 (p.15-16)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-048",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Qualifying visit / same-day",
    "codes": "Visit definition",
    "question": "What counts as a billable FQHC visit in Texas, and when can I bill two in one day?",
    "answer": "A visit is a face-to-face, telemedicine, or telehealth encounter with a physician, PA, NP, CNM, visiting nurse, clinical psychologist, LCSW, LMFT, LPC, other mental health professional, dentist, dental hygienist, or optometrist. Same-day encounters at one location are one visit unless (1) a later illness/injury needs more diagnosis or treatment, or (2) the patient has a medical visit plus an 'other' health visit (mental health, dental, optometry, or a THSteps medical checkup). Lab, radiology, LVN, RN, nutritionist and dietitian services are not encounters.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1.2 (p.13-14); 1 TAC §355.8261(b)(12)-(13)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-049",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Payment codes",
    "codes": "G0466, G0467, G0468, G0469, G0470",
    "question": "Does Texas Medicaid recognize the Medicare FQHC G-codes?",
    "answer": "Yes, G0466-G0470 appear in the TMPPM table of 'FQHC Encounter Services' reimbursable under the FQHC's NPI. The handbook does not explain when to use them instead of T1015.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1.2 (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - listed, but usage instructions were not found in this section.",
    "id": "TX-050",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health",
    "codes": "90791, 90792, 90832-90838, 90846, 90847, 90853, 90899, 96116, 96130, 96132, 96136; modifiers AH, AJ, AM, U1, U2",
    "question": "How are mental health services billed by a Texas FQHC?",
    "answer": "Mental health services are billed with their own procedure codes (listed in the handbook) using modifier AH, AJ, AM, U1 or U2. Codes 90833, 90836 and 90838 cannot be done by a psychologist.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1.2 Mental Health Services (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-051",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Family planning / LARC",
    "codes": "J7296, J7297, J7298, J7300, J7301, J7307; 58300; modifiers FP, U8",
    "question": "How are family planning visits and LARCs billed by a Texas FQHC?",
    "answer": "Bill the E/M code (or a LARC code) with a family planning diagnosis for the encounter rate. Up to three family planning encounters per client per year are paid; the annual exam (modifier FP) is allowed once per state fiscal year. LARC devices are paid on top of the encounter payment; use modifier U8 for 340B-purchased devices. 58300 must be on the same claim as J7296, J7297, J7298, J7300 or J7301 and is informational only.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1.2 (p.13-14); §4.3.1 (p.15)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-052",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate setting",
    "codes": "PPS / APPS; MEI",
    "question": "How is a Texas FQHC's Medicaid encounter rate set and updated?",
    "answer": "FQHCs are paid provider-specific PPS encounter rates under 1 TAC §355.8261. Under PPS, increases follow the MEI for primary care. Under the alternative (APPS) method, the effective rate is updated by MEI plus 0.5%. A center can request an adjustment if costs rise more than that. New FQHCs file a projected cost report within 90 days of designation, and a new site of an existing FQHC gets the parent's effective rate. FQHCs are exempt from mandated rate reductions except for HHSC Family Planning.",
    "claim_format": "-",
    "source_title": "1 Tex. Admin. Code §355.8261 - FQHC Services Reimbursement (read via the Cornell LII mirror; official text is in the Texas SOS rule viewer, which our checker cannot fetch)",
    "source_url": "https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-355-8261",
    "source_section": "§355.8261(a)-(b); TMPPM §4.1.1, §4.3.2 (p.10, 16)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "TX-053",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossover / duals",
    "codes": "Crossover",
    "question": "How does Texas Medicaid pay FQHC Medicare crossover claims?",
    "answer": "Texas Medicaid pays the lesser of (1) the coinsurance and full deductible, or (2) the Medicaid encounter rate (or allowed fee) minus the Medicare payment, and never less than the full deductible. If Medicare's payment equals or exceeds the Medicaid allowed amount, no coinsurance is paid. The client has no liability for the balance.",
    "claim_format": "Same form filed with Medicare",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.3.2.1 (p.17)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-054",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Hospital services",
    "codes": "Physician NPI",
    "question": "Can a Texas FQHC bill hospital services (e.g., a delivery) under the FQHC?",
    "answer": "No. Inpatient or outpatient hospital services are not FQHC encounters. An employed physician may bill them under their own enrolled number, paid at the physician fee schedule.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.3.1 (p.15)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-055",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "STAR / STAR+PLUS / STAR Kids / STAR Health MCOs",
    "payer_type": "Managed Medicaid",
    "category": "Office visits / encounter payment",
    "codes": "PPS supplemental (wrap)",
    "question": "How do I get reimbursed for office visits for Texas managed Medicaid (STAR MCOs)?",
    "answer": "The FQHC bills the client's MCO, which sets its own reimbursement (MCOs are not bound to the Medicaid fee schedule). If the MCO pays less than the FQHC's PPS/APPS rate, the state reimburses the difference at least quarterly. That amount is the effective rate minus the MCO's baseline contract payment, ignoring incentive or bonus payments. Disputes go first to the MCO appeal process, then HHSC.",
    "claim_format": "Per MCO",
    "source_title": "1 Tex. Admin. Code §355.8261 - FQHC Services Reimbursement (read via the Cornell LII mirror; official text is in the Texas SOS rule viewer, which our checker cannot fetch)",
    "source_url": "https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-355-8261",
    "source_section": "§355.8261(b)(11) and (c); TMPPM Medicaid Managed Care Handbook (p.26)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "TX-056",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "STAR / STAR+PLUS / STAR Kids / STAR Health MCOs",
    "payer_type": "Managed Medicaid",
    "category": "Plans / PCP role",
    "codes": "FQHC as PCP / main dentist",
    "question": "Can a Texas FQHC be a primary care provider or main dentist in managed care?",
    "answer": "Yes. FQHCs are eligible to serve as primary care providers and as main dentists. Providers contact each MCO or DMO for enrollment. STAR Health (foster care) is administered statewide by Superior HealthPlan.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Medicaid Managed Care Handbook (October 2026)",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_12_medicaid_managed_care.pdf",
    "source_section": "§2.4.1 (p.23); program overview",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the full list of STAR MCOs by service area was not compiled for v1.",
    "id": "TX-057",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "STAR / STAR+PLUS / STAR Kids / STAR Health MCOs",
    "payer_type": "Managed Medicaid",
    "category": "Out-of-network / new members",
    "codes": "IHCP enrolled as FQHC",
    "question": "Do Texas MCOs pay out-of-network FQHCs for new members?",
    "answer": "For newly enrolled clients, MCOs must pay existing out-of-network Medicaid providers for medically necessary covered services for up to 90 days. MCOs are not responsible for unauthorized nonemergency out-of-network services, except when the provider is an Indian Health Care Provider enrolled as an FQHC.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Medicaid Managed Care Handbook (October 2026)",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_12_medicaid_managed_care.pdf",
    "source_section": "Managed care handbook (p.27)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-058",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "T1015 + detail lines",
    "question": "How do I get reimbursed for office visits for Louisiana Medicaid (fee-for-service)?",
    "answer": "Bill the medical encounter on the CMS-1500 with T1015 on the first line. Each service performed follows on its own detail line with its procedure code and a zero or usual-and-customary charge. The encounter (paid at the center's all-inclusive PPS rate) covers everything that day and incidental follow-up services. Lab, x-ray, prescription pickups or referrals alone are not billable encounters.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Encounter Billing Guidelines / Medical Encounters (PDF p.33)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-059",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Healthy Louisiana MCOs",
    "payer_type": "Managed Medicaid",
    "category": "Office visits / encounter payment",
    "codes": "T1015; PPS floor",
    "question": "How do I get reimbursed for office visits for Louisiana managed Medicaid (Healthy Louisiana)?",
    "answer": "Bill the member's Healthy Louisiana plan. By rule, the MCO must pay FQHCs at least what LDH would pay through fee-for-service, or the PPS or alternative payment rate in effect on the date of service, for each encounter. The plan manuals were not reviewed for v1, so confirm claim format with the plan. LDH's FFS method is T1015 on CMS-1500 with detail lines.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "La. Admin. Code tit. 50, Part I, §3509 - Managed Care Reimbursement Methodology (official Title 50 compilation, Louisiana Office of the State Register)",
    "source_url": "https://doa.louisiana.gov/media/ogee2gb4/50.docx",
    "source_section": "LAC 50:I.3509.L.3",
    "last_verified": "2026-10-30",
    "confidence": "High for the payment floor (re-read 2026-10-30 in the official Title 50 compilation); plan-specific billing not verified.",
    "id": "LA-060",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day limits",
    "codes": "One medical, one BH, one dental per day",
    "question": "How many FQHC encounters per day can Louisiana Medicaid pay?",
    "answer": "One medical, one behavioral health and one dental encounter per day. Multiple core encounters the same day at one location are one visit unless a later illness/injury needs more treatment. Services may not be delayed or split to bill extra encounters. Fluoride varnish is paid only with an office visit or screening on the same day.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Encounter Visits (PDF p.30-32); §22.1",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-061",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health",
    "codes": "H2020",
    "question": "How are behavioral health encounters billed by a Louisiana FQHC?",
    "answer": "Bill the CMS-1500 with H2020 as the first line and detail procedure codes. The FQHC is billing provider. The practitioner's ID goes in the attending field (e.g., psychiatric NP/CNS). For clinical psychologists and LCSWs, the manual's practitioner subsections list the FQHC ID as both billing and attending. A behavioral-health-specific service is required (E/M alone only for certain specialties), and a group session alone is not a billable encounter. LPC, LMFT, PLPC, PLMFT and LMSW services are 'other ambulatory services' paid at the all-inclusive (PPS) rate on file.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Behavioral Health Encounters (PDF p.34-36)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-062",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "D0999",
    "question": "How are dental encounters billed by a Louisiana FQHC?",
    "answer": "Dental services go on the ADA claim form with encounter code D0999, followed by detail lines for each dental service. D0999 can be billed the same day as T1015, T1015-TH, T1015-EP and/or H2020.",
    "claim_format": "ADA dental claim",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Dental Encounters / EPSDT note (PDF p.36-38)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-063",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Preventive / EPSDT / OB",
    "codes": "T1015-EP; T1015-TH",
    "question": "How are EPSDT well-child and obstetric visits billed by a Louisiana FQHC?",
    "answer": "EPSDT visits use T1015 with modifier EP on the CMS-1500/837P, with detail lines for each screening (e.g., immunizations, vision, hearing, developmental and perinatal depression screening). The physician, APRN or PA must be present. Obstetric visits use T1015 with modifier TH plus all services that day.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 EPSDT; Medical Encounters (PDF p.33, 38)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-064",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "After-hours (adjunct) add-on",
    "codes": "Adjunct codes + T1015",
    "question": "Does Louisiana Medicaid pay FQHCs extra for after-hours visits?",
    "answer": "Yes. Adjunct service codes are paid as a flat FFS add-on to the encounter for services on weekends, state holidays, or 5 p.m.-8 a.m. weekdays. Report the adjunct code as a detail line with T1015 (never as the only detail line), one per day, and document the time. Not allowed for dental-only encounters.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Payment for Adjunct Services / Adjunct Services (PDF p.31, 37)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-065",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "LARC",
    "codes": "LARC device + insertion codes",
    "question": "Are LARCs paid outside the PPS rate in Louisiana?",
    "answer": "Yes. LARCs are paid outside PPS at the lesser of the Medicaid FFS rate or actual acquisition cost (340B). Include the LARC and insertion codes as detail lines with the medical encounter; they cannot be the only detail lines.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Long Acting Reversible Contraceptives (PDF p.32)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-066",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossover / duals",
    "codes": "UB-04",
    "question": "How does a Louisiana FQHC bill Medicaid for dual-eligible patients?",
    "answer": "Medicaid pays the Medicare coinsurance up to the Medicaid encounter rate. Bill Medicare first, then bill Medicaid on the UB-04 with the Medicare EOB. This is the only case where the UB-04 is used for FQHC services; straight Medicaid claims use the CMS-1500.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Medicare/Medicaid Dual Eligible Billing (PDF p.39)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-067",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate setting",
    "codes": "PPS; MEI July 1",
    "question": "How is a Louisiana FQHC's PPS rate set and updated?",
    "answer": "A newly enrolled FQHC's initial rate is the weighted average cost per encounter for all FQHCs. Rates are adjusted each July 1 by the MEI and for HRSA-approved changes in scope, which require a cost report and the Services Facility Survey. Out-of-state trade-area FQHCs get the lesser of the Louisiana average or their home-state rate.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Rates (PDF p.28-29)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-068",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Community health workers",
    "codes": "CHW",
    "question": "Can a Louisiana FQHC get paid for community health worker services?",
    "answer": "Yes. FQHCs receive the CHW rate on file in addition to the encounter payment on the same date, following Professional Services Manual Ch. 5 policy.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Community Health Worker Services",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-069",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Healthy Louisiana MCOs",
    "payer_type": "Managed Medicaid",
    "category": "Plans / contacts",
    "codes": "Aetna; AmeriHealth Caritas; Healthy Blue; Humana; LHCC",
    "question": "Which Healthy Louisiana MCOs are active, and what's changing?",
    "answer": "LDH did not renew UnitedHealthcare after 12/31/2025. 2026 plans: Aetna Better Health, AmeriHealth Caritas Louisiana, Healthy Blue, Humana and Louisiana Healthcare Connections. Healthy Blue ends 12/31/2026; its members move to one of the other four on 1/1/2027.",
    "claim_format": "-",
    "source_title": "LDH - Medicaid Health Plan Transition 2027 / LDH news release Dec 12, 2025",
    "source_url": "https://www.ldh.la.gov/medicaid/medicaid2027",
    "source_section": "Transition 2027 page; Dec 12, 2025 release (ldh.la.gov/news/7615)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-070",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "Modifier 95; POS 02 / 10",
    "question": "How does a Louisiana FQHC bill telemedicine?",
    "answer": "The FQHC chapter points to Professional Services Chapter 5, Section 5.1 (issued 08/14/25). Telemedicine must use two-way, real-time audio and video that is HIPAA-compliant. There is no originating-site restriction, so the home qualifies. Covered services in the Telemedicine appendix of the CPT manual, plus services this manual explicitly lists, are reimbursable. Only the distant-site provider is paid, at the same level as in person, and it must be enrolled in Louisiana Medicaid. Add modifier 95 and POS 02 (not home) or 10 (home). Claims need both or they won't be paid. The record must show the service was delivered by telemedicine. Chapter 5 doesn't say how this interacts with the T1015 encounter, so confirm with LDH or the MCO.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 5 Professional Services, Sec. 5.1 Telemedicine/Telehealth (issued 08/14/25)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/PS/PS_5.1_Telemed_08-14-25.pdf",
    "source_section": "Ch.5 Sec.5.1 Telemedicine/Telehealth pp.1-2; FQHC Ch.22 §22.4 Encounter Billing Guidelines",
    "last_verified": "2026-10-30",
    "confidence": "Medium - general professional-services policy; FQHC-specific encounter interaction not stated.",
    "id": "LA-071",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "UB format; encounter rate",
    "question": "How do I get reimbursed for office visits for New Mexico Medicaid (fee-for-service)?",
    "answer": "FQHCs bill on the UB claim form (UB-92 or its successor). HCA's guidance says to show any prior payment from Medicare or other insurance. FFS pays the full FQHC encounter rate minus all prior payments; if Medicare already paid more, payment is zero. Interim payment is made on claims and settled through annual cost reports.",
    "claim_format": "UB-04 / 837I",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.15 NMAC; Supplement 16-13 'Fee for Service Claims' (p.1-2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - Supplement 16-13 is from 2017; the rule is current (eff. 7/1/2024). Check the current HCA billing instructions.",
    "id": "NM-072",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "Turquoise Care MCOs (BCBSNM, Molina, Presbyterian, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Office visits / encounter payment",
    "codes": "UB (rev 0919 for non-specialized BH); CMS-1500 for specialized BH",
    "question": "How do I get reimbursed for office visits for New Mexico managed Medicaid (Turquoise Care)?",
    "answer": "Bill the member's Turquoise Care MCO. FQHCs with specific supplemental agreements with HCA get supplemental payments for managed care clients per those agreements. HCA's 2017 MCO guidance says: routine evaluation/therapy behavioral health is billed on the UB as an encounter (revenue code 0919) at the encounter rate; specialized BH services go on the CMS-1500 at no less than the FFS encounter rate unless negotiated; and when another payer paid first on a CMS-1500, the FQHC may bill the MCO on either format.",
    "claim_format": "UB or CMS-1500 (by service)",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "8.310.4.15.D NMAC; Supplement 16-13 items 2-3 (p.3-6)",
    "last_verified": "2026-10-30",
    "confidence": "Low/Medium - managed care guidance is from 2017 (Centennial Care era); confirm with current MCO manuals.",
    "id": "NM-073",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Qualifying visit / same-day",
    "codes": "Visit definition",
    "question": "What counts as an FQHC visit in New Mexico, and when can two be paid in one day?",
    "answer": "A visit is a face-to-face encounter with a physician, PA, NP, nurse midwife, visiting nurse, clinical psychologist or clinical social worker. Same-day encounters at one location are one visit unless a later illness/injury needs more treatment, or the client has a dental visit, or a medical plus a mental health visit. HCA told MCOs to pay no more than one encounter per day except in those cases, including Medicare crossovers that split one visit across claims.",
    "claim_format": "UB-04 / 837I",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.15.C NMAC; Supplement 16-13 item 5 (p.7-8)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-074",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "D5110-D5214 dentures; D2751-D2792 crowns",
    "question": "How are FQHC dental services paid in New Mexico?",
    "answer": "Dental is billed on the ADA claim form and paid at the FQHC encounter rate, except listed high-cost dentures (D5110, D5120, D5130, D5140, D5211-D5214) and crowns (D2751, D2752, D2791, D2792), which are paid at fee schedule.",
    "claim_format": "ADA dental claim",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "Item 1 Dental (p.2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - 2017 guidance.",
    "id": "NM-075",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "LARC",
    "codes": "Rev 0636",
    "question": "Are LARCs paid on top of the NM FQHC encounter rate?",
    "answer": "Yes. LARC devices are paid in addition to the encounter rate, billed on the UB line using revenue code 0636 (see FQHC Supplement 16-09 for allowed codes).",
    "claim_format": "UB-04 / 837I",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "Fee for Service Claims (p.2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - 2017 guidance.",
    "id": "NM-076",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Prenatal / delivery",
    "codes": "59409, 59412, 59414, 59514, 59525, 59612, 59620",
    "question": "How are prenatal visits and deliveries billed by a New Mexico FQHC?",
    "answer": "Prenatal and postpartum visits are billed as encounters at the encounter rate. Deliveries may be billed on the CMS-1500 using the delivery-only codes listed (59409, 59412, 59414, 59514, 59525, 59612, 59620) at fee schedule. Do not use global maternity codes.",
    "claim_format": "UB + CMS-1500 for delivery",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "Item 4 (p.7)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - 2017 guidance.",
    "id": "NM-077",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services away from center",
    "codes": "Out-of-clinic / inpatient visits",
    "question": "Is a New Mexico FQHC paid its encounter rate for home, nursing facility or hospital visits?",
    "answer": "HCA's guidance says the FQHC is still paid the encounter rate when the practitioner sees the patient in another setting. The rule says FQHC services are not covered in a hospital, and off-site services count only if the practitioner's agreement requires them to seek payment from the FQHC.",
    "claim_format": "UB or CMS-1500",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "Item 3 (p.6); 8.310.4.12 and 8.310.4.14 NMAC",
    "last_verified": "2026-10-30",
    "confidence": "Low - the 2017 supplement and the current rule differ on hospital settings; verify with HCA.",
    "id": "NM-078",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Pharmacy",
    "codes": "Pharmacy",
    "question": "Can a New Mexico FQHC bill a separate encounter for pharmacy services?",
    "answer": "No. Pharmacy services related to a medical, behavioral health or dental encounter are included in that encounter. Dispensing requires a licensed drug clinic license under the Pharmacy Practice Act.",
    "claim_format": "UB-04 / 837I",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.12 NMAC (covered services - pharmacy)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-079",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate setting / cost reports",
    "codes": "Interim rate; cost settlement",
    "question": "How is a New Mexico FQHC's rate set?",
    "answer": "A new FQHC's initial interim rate is the interim rate set by Medicare. FQHCs file annual cost reports within Medicare's time frames (no extensions), and HCA does a final settlement on audited allowable costs, using Medicare productivity standards but not Medicare cost limits. HCA aims to finish initial review within 150 days of receiving all materials.",
    "claim_format": "UB-04 / 837I",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.15.A-B NMAC",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-080",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "Turquoise Care MCOs (BCBSNM, Molina, Presbyterian, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / contacts",
    "codes": "BCBSNM; Molina; Presbyterian; UnitedHealthcare",
    "question": "Which Turquoise Care MCOs serve New Mexico Medicaid?",
    "answer": "Four MCOs as of 7/1/2024: Blue Cross Blue Shield of New Mexico, Molina Healthcare, Presbyterian Health Plan and UnitedHealthcare Community Plan. Children in state custody are enrolled in Presbyterian. HCA program questions: TCInfo@hca.nm.gov.",
    "claim_format": "-",
    "source_title": "NM Health Care Authority - Turquoise Care Health Plans",
    "source_url": "https://www.hca.nm.gov/turquoise-care-health-plans/",
    "source_section": "Turquoise Care Health Plans page",
    "last_verified": "2026-10-30",
    "confidence": "High for the plan list; MCO FQHC billing manuals were not reviewed for v1.",
    "id": "NM-081",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health practitioners",
    "codes": "LISW, LPCC, LMFT, psychologist",
    "question": "Which behavioral health practitioners are covered in a New Mexico FQHC?",
    "answer": "Covered: board-eligible or certified psychiatrists, licensed clinical psychologists, LISW, LPCC, LMFT, and psychiatric clinical nurse specialists employed by or contracted with the FQHC. Services by LMSWs, psychology associates and master's-level licensed counselors are reimbursed when furnished under the supervision described in 8.310.8.10 NMAC.",
    "claim_format": "UB-04 / 837I",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.12 NMAC (covered services - mental health)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-082",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How does a Texas FQHC request a rate change for a change in scope?",
    "answer": "File a Change of Effective Rate Cost Report with at least six months of financial data and documentation of the change in scope, or of operating efficiently. You can file any time during the fiscal year, up to five calendar months after it ends. HHSC decides on a new interim base rate within 60 days, at 100% of reasonable costs, then follows up with the As-Filed Medicare Cost Report. A change in scope includes:\n- added or deleted services\n- changes in the magnitude, intensity or character of services\n- higher intensity from the patient mix (for example HIV/AIDS, homeless, elderly or migrant patients)\n- changes in services or provider mix\n- capital or regulatory cost changes\n- changes in technology or medical practice\n- IME/GME costs\n- HRSA-approved scope changes\n\nHHSC can also adjust the rate on its own after an audit.",
    "claim_format": "-",
    "source_title": "1 Tex. Admin. Code §355.8261 - FQHC Services Reimbursement (read via the Cornell LII mirror; official text is in the Texas SOS rule viewer, which our checker cannot fetch)",
    "source_url": "https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-355-8261",
    "source_section": "§355.8261(b)(6), (7)(A), (10)(C)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "TX-083",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS vs APPS election",
    "codes": "",
    "question": "How does a new Texas FQHC choose PPS or APPS?",
    "answer": "New in-state FQHCs get a letter from HHSC and the FQHC Prospective Payment System Form. An authorized representative must sign it and return it within 30 days of the letter date, choosing PPS or APPS. If HHSC doesn't receive it in time, HHSC selects PPS. The new FQHC's initial interim base rate is the lesser of 80% of anticipated reasonable costs or 80% of the average FQHC rate on January 1 of that year.",
    "claim_format": "-",
    "source_title": "1 Tex. Admin. Code §355.8261 - FQHC Services Reimbursement (read via the Cornell LII mirror; official text is in the Texas SOS rule viewer, which our checker cannot fetch)",
    "source_url": "https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-355-8261",
    "source_section": "§355.8261(b)(5)(A); (b)(10)(A)(i)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "TX-084",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report filing",
    "codes": "",
    "question": "Which cost reports must Texas FQHCs send to HHSC, and when?",
    "answer": "Send a copy of the Final Audited Medicare Cost Report within 30 days of receiving it from Medicare (TMPPM: to TMHP Medicaid Audit). Low Utilization filers send a copy within 30 days of filing with Medicare. New FQHCs file a projected cost report within 90 days of designation and an As-Filed report within 5 calendar months after their first full fiscal year. Settlement is completed within 11 months of receiving the report. HHSC may hold payment until a required cost report is received.",
    "claim_format": "-",
    "source_title": "1 Tex. Admin. Code §355.8261 - FQHC Services Reimbursement (read via the Cornell LII mirror; official text is in the Texas SOS rule viewer, which our checker cannot fetch)",
    "source_url": "https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-355-8261",
    "source_section": "§355.8261(b)(8)-(10); TMPPM Clinics §4.1.1 (p.10)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "TX-085",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Sites / satellites",
    "codes": "FQS identifier",
    "question": "How do Texas FQHC satellite sites enroll and bill?",
    "answer": "FQHCs must report every affiliated satellite and its address to TMHP, and satellites must be HRSA-approved. A satellite can enroll with a Federally Qualified Satellite (FQS) identifier tied to the parent NPI and TIN, sharing one provider agreement and one combined cost report. A satellite that bills directly needs its own NPI and files a separate cost report. FQHCs and satellites must enroll in Medicare (a CMS waiver covers initial enrollment). Look-alikes don't have to. Send a current Notice of Grant Award to TMHP every year, and file the FQHC Affiliation Affidavit listing contracted PPS services.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1 Enrollment (p.9-10)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-086",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "After-hours / referrals / documentation",
    "codes": "",
    "question": "What counts as after-hours care at a Texas FQHC, and does it need a referral?",
    "answer": "After-hours means weekends, federal holidays, or before 8 a.m. and after 5 p.m. on weekdays. It doesn't need a referral. Prior authorization may apply as described in the service sections. All services need documentation of medical necessity and can be reviewed and recouped later.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.1.3-4.2 (p.14)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-087",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "Texas Medicaid (TMHP fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Rate reductions / NCCI",
    "codes": "",
    "question": "Do Texas Medicaid rate cuts and NCCI edits apply to FQHCs?",
    "answer": "FQHCs are exempt from mandated rate reductions, except for HHSC Family Planning services. NCCI edits and MUEs apply to the HCPCS and CPT codes in the manual. Where Texas Medicaid limits are stricter than NCCI MUEs, the Texas limits apply.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Clinics and Other Outpatient Facility Services Handbook (October 2026), Sec. 4 FQHC",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_05_clinics_other_outpatient_fac_srvs.pdf",
    "source_section": "§4.3.2; §4.3.2.2 (p.16-17)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-088",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "STAR / STAR+PLUS / STAR Kids / STAR Health MCOs",
    "payer_type": "Managed Medicaid",
    "category": "MCO timely filing",
    "codes": "",
    "question": "What is the timely filing limit for Texas Medicaid MCO claims?",
    "answer": "95 days from the date of service to the correct MCO or DMO. If you filed with the wrong plan in time, refile within 95 days of the other carrier's R&S report date, with proof. After other insurance, refile within 95 days of that payer's decision. Newborn claims go to the mother's MCO within 95 days. Claims the MCO receives after 95 days are denied. Appeals go to the MCO or DMO, and providers can complain to HHSC after using the plan's process.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Medicaid Managed Care Handbook (October 2026)",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_12_medicaid_managed_care.pdf",
    "source_section": "§2.9.1 Filing Deadlines; §2.10 (p.31)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-089",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Texas",
    "payer": "STAR / STAR+PLUS / STAR Kids / STAR Health MCOs",
    "payer_type": "Managed Medicaid",
    "category": "FQHCs as PCP / main dentist",
    "codes": "",
    "question": "Can Texas FQHCs be a managed care PCP or main dentist?",
    "answer": "Yes. The managed care handbook lists FQHCs among the providers eligible to be PCPs and main dentists. THSteps medical services are self-referred. Note that MCOs aren't responsible for unauthorized non-emergency out-of-network services, except from an Indian Health Care Provider enrolled as an FQHC.",
    "claim_format": "-",
    "source_title": "Texas Medicaid Provider Procedures Manual, Vol. 2 - Medicaid Managed Care Handbook (October 2026)",
    "source_url": "https://www.tmhp.com/sites/default/files/file-library/resources/provider-manuals/tmppm/pdf-chapters/2026/2026-10-october/2_12_medicaid_managed_care.pdf",
    "source_section": "§2.4.1 Enrolling as a PCP or Main Dentist (p.22-23); §2.6.3 Out-of-Network Reimbursement (p.27)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "TX-090",
    "region": "Region 6",
    "state_abbr": "TX"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Service limits / exclusions",
    "codes": "",
    "question": "Does Louisiana limit FQHC visits, and what's not separately billable?",
    "answer": "There is no annual limit on FQHC encounters. Only FQHC or other ambulatory services can be billed. DSMT alone isn't an encounter and can't be billed as a separate one. Follow-up visits on the same date as an earlier billed visit, consultation, ER visit or hospital admission aren't paid. Incident-to services aren't separately billable, including:\n- injections\n- on-site labs, spirometry, EKG and x-ray\n- immunizations\n- hearing and vision screens\n- prescriptions",
    "claim_format": "-",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.1 Service Limits / Exclusions (p.10 of 12)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-091",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Sites / satellites / mobile",
    "codes": "",
    "question": "How do Louisiana FQHC satellites and mobile units enroll?",
    "answer": "Each satellite needs its own provider agreement and provider number. A mobile clinic can't be enrolled; bill its services under the main center's number. Tell Medicaid in writing within seven working days of:\n- loss of FQHC status\n- grant budget-period changes\n- satellite openings or closings\n- other listed changes\n\nOut-of-state FQHCs in trade areas (bordering TX, AR and MS counties) must meet Louisiana's enrollment rules and send a letter confirming their home-state rate. They're paid the lesser of the Louisiana statewide average or their home-state PPS rate.",
    "claim_format": "-",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.2 Satellite/Mobile Clinics, Changes (p.6 of 7); §22.4 Out of State/Trade Area FQHC (p.2 of 12)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-092",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How does a Louisiana FQHC get a PPS change-in-scope adjustment?",
    "answer": "A change in scope means adding, removing or relocating sites, or adding or deleting specialty or non-primary services that weren't in the baseline rate. A relocation that doesn't change the budget, services, patients or providers doesn't count. Notify LDH/BHSF in writing and include:\n- the current and change budgets\n- a detailed request\n- cost reports for prior years\n- the impact on total and Medicaid visits\n\nThe change must be HRSA-approved and reported on the Services Facility Survey (Appendix B). An interim rate takes effect the next SFY. The final rate uses the first two years of audited Medicaid cost reports. Cost reports aren't accepted for rate changes without a HRSA-approved change. Rate appeals must be in writing.",
    "claim_format": "-",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.4 Adjustment of Rate; Appeals; Cost Report Submission (pp.2-3 of 12)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-093",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "Louisiana",
    "payer": "Louisiana Medicaid (fee-for-service, Gainwell)",
    "payer_type": "Medicaid FFS",
    "category": "Records / audits",
    "codes": "",
    "question": "How long must Louisiana FQHCs keep records, and are cost reports audited?",
    "answer": "Keep records for at least six years from the date of service, or longer if state law requires. All cost reports can be desk-audited or field-audited.",
    "claim_format": "-",
    "source_title": "Louisiana Medicaid Services Manual, Ch. 22 - Federally Qualified Health Centers (Sec. 22.4 issued 09/08/26)",
    "source_url": "https://www.lamedicaid.com/provweb1/providermanuals/manuals/FQHC/FQHC.pdf",
    "source_section": "§22.3 Retention of Records (p.2 of 2); §22.4 Audits",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "LA-094",
    "region": "Region 6",
    "state_abbr": "LA"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing",
    "codes": "90 days; 210-day cap",
    "question": "What is New Mexico Medicaid's timely filing limit?",
    "answer": "MAD must receive claims within 90 calendar days of the date of service. If another payer pays or denies first (Medicare, an MCO, a Medicare replacement plan or other insurance), file within 90 days of that payer's EOB or RA, but no later than 210 days from the date of service. The same applies to claims for deductibles, coinsurance and copays. For retroactive eligibility, file within 90 days of the date eligibility was added. A newly enrolled provider files within 90 days of PPA approval, capped at 210 days. Denials for primary-payer administrative errors must be appealed to that payer.",
    "claim_format": "UB-04 / 837I",
    "source_title": "8.302.2 NMAC - Billing for Medicaid Services, NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.302.0002.html",
    "source_section": "8.302.2.11.A(1)-(5) NMAC",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-095",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Prior approval / utilization review",
    "codes": "",
    "question": "Do New Mexico FQHC services need prior approval?",
    "answer": "Some procedures need prior approval from MAD or its designee. All services can be reviewed before, during or after payment, even with prior approval, and approval doesn't guarantee eligibility. Verify eligibility and other insurance at each visit. You can ask for a re-review and reconsideration under 8.350.2 NMAC.",
    "claim_format": "-",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.13 NMAC; 8.310.4.11 NMAC",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-096",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Sites / mobile units / setting",
    "codes": "",
    "question": "Where can New Mexico FQHC services be delivered?",
    "answer": "Only in outpatient settings, including the client's home (which can be a nursing facility or other institution used as home). Not in a hospital as defined in SSA §1861(e)(1). Each permanent unit needs its own FQHC certification. Mobile units must have fixed, scheduled locations. Other ambulatory FFS services can be paid if the FQHC meets that service's licensing and certification rules.",
    "claim_format": "-",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.14 NMAC",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-097",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Enrollment / practitioners",
    "codes": "",
    "question": "Who can enroll as an FQHC in New Mexico, and do practitioners enroll too?",
    "answer": "Eligible entities once MAD approves the participation agreement:\n- Section 330 grantees and their subgrantees\n- look-alikes the Secretary determines qualify\n- tribal and urban Indian outpatient programs\n\nPractitioners employed by or contracted with the FQHC must also enroll in NM Medicaid.",
    "claim_format": "-",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.10 NMAC",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-098",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "NM Medicaid (HCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Change of ownership",
    "codes": "",
    "question": "What happens to New Mexico FQHC payments on a change of ownership?",
    "answer": "HCA may withhold payment on current and pending claims until it decides on recoupment from final cost reports. It won't withhold if the new or previous owner agrees in writing to cover any recoupment.",
    "claim_format": "-",
    "source_title": "8.310.4 NMAC - Federally Qualified Health Center Services (eff. 7/1/2024), NM State Records Center & Archives",
    "source_url": "https://www.srca.nm.gov/parts/title08/08.310.0004.html",
    "source_section": "8.310.4.15.E NMAC",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NM-099",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "Turquoise Care MCOs (BCBSNM, Molina, Presbyterian, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Same-day encounters (MCO)",
    "codes": "",
    "question": "Can a New Mexico MCO pay more than one FQHC encounter per day?",
    "answer": "Under HCA's 2017 guidance, MCOs should pay only one encounter per day. Exceptions are a second visit with a different diagnosis, or distinct visit types, such as:\n- medical plus dental\n- medical plus a separate BH service by a different provider\n- distinct, non-overlapping specialized BH services\n\nMedicare crossovers that split lab from the visit must not produce two encounters. Overpayments have been recouped.",
    "claim_format": "-",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "Item 5 (p.7-8)",
    "last_verified": "2026-10-30",
    "confidence": "Low/Medium - 2017 (Centennial Care era) guidance; confirm with current Turquoise Care MCO manuals.",
    "id": "NM-100",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "New Mexico",
    "payer": "Turquoise Care MCOs (BCBSNM, Molina, Presbyterian, UnitedHealthcare)",
    "payer_type": "Managed Medicaid",
    "category": "Dental (MCO)",
    "codes": "ADA claim; D5110-D5214, D2751-D2792 at fee schedule",
    "question": "How do New Mexico MCOs pay FQHC dental?",
    "answer": "Bill MCOs on the ADA dental claim. They pay the FQHC encounter rate, except the listed high-cost denture and crown codes, which are paid at the fee schedule (in place since 2014).",
    "claim_format": "ADA dental claim",
    "source_title": "NM Medical Assistance Program Manual Supplement 16-13 - Billing and Payment to FQHCs, RHCs, HB-RHCs and IHS FQHCs (Jan 6, 2017)",
    "source_url": "https://www.hca.nm.gov/wp-content/uploads/16-13.pdf",
    "source_section": "Item 1 Dental (p.2)",
    "last_verified": "2026-10-30",
    "confidence": "Low/Medium - 2017 guidance; confirm with current Turquoise Care MCO manuals.",
    "id": "NM-101",
    "region": "Region 6",
    "state_abbr": "NM"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "FQHC encounter procedure code (see DMS code list)",
    "question": "How do I bill an FQHC visit to Arkansas Medicaid?",
    "answer": "Bill a core-service encounter with the 'FQHC Encounter Service' procedure code on the CMS-1500 (paper) or the electronic equivalent. The encounter includes all services and supplies incident to it. Paper claims use type of service code 9. Medicaid pays your current established rate per encounter. The specific code is on DMS's linked FQHC procedure code list, which isn't reproduced here. Each claim can cover only one beneficiary.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "261.000 Introduction to Billing; 262.110 FQHC Encounter Service (eff. 2-1-22)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-102",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Billable visit definition",
    "codes": "",
    "question": "What counts as an FQHC core-service encounter in Arkansas?",
    "answer": "A face-to-face contact between an FQHC patient and one of these practitioners: physician, PA, NP, licensed clinical psychologist, LCSW, LPC, licensed mental health counselor or LMFT. Services and supplies incidental to the contact are included. 'Other ambulatory services' encounters, such as dental or visual care, are a separate type and are billed under that program.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "214.000; 214.100 (eff. 1-1-22); 214.200",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-103",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "",
    "question": "Can an Arkansas FQHC bill more than one encounter per day?",
    "answer": "Usually not. Seeing several professionals, or the same professional more than once, on the same day at one location is a single encounter. The exception is when the patient later has an illness or injury that needs more diagnosis or treatment. A separate family planning encounter is allowed during a core-service visit, but not on the same day as a family planning surgery. An encounter isn't paid separately on the same day as an OB/GYN procedure reported by CPT code.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "252.100 A.2 (PPS methodology)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-104",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Incident-to and ancillary services",
    "codes": "",
    "question": "Are labs and X-rays billed separately by Arkansas FQHCs?",
    "answer": "Incident-to services are part of the encounter and aren't separate encounters, even on another day (for example, daily blood pressure checks). You may list lab, X-ray and machine tests by CPT code at your usual charge. Medicaid denies these lines and keeps them for tracking only. Specimen handling fees aren't covered. Specimen collection is covered separately only when the specimen goes to a reference lab.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "214.110; 214.111; 214.112; 262.410 Ancillary Charges",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-105",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Benefit limits",
    "codes": "",
    "question": "Is there an annual visit limit for adult Arkansas Medicaid FQHC patients?",
    "answer": "Yes. Beneficiaries 21 and older get 16 core-service encounters per state fiscal year (July 1 to June 30). That limit is shared with physician, CNM, RHC, APRN and certain dentist or optometrist medical visits. These don't count toward the limit: inpatient visits (one per covered day), OB/GYN procedures billed by CPT code, postpartum encounters, family planning, and MAT for OUD when it's the primary diagnosis. Extensions are automatic for malignant neoplasm, HIV/AIDS, renal failure and OUD treated with MAT.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "220.000 Benefit Limits (eff. 7-1-25); 220.200 Extension of Benefits",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-106",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "Telemedicine procedure code + TOS Y",
    "question": "How do Arkansas FQHCs bill telemedicine?",
    "answer": "Section II says to use the FQHC telemedicine procedure code, with type of service code Y on paper claims. The charge should reflect only the telemedicine cost, such as line charges. Medicaid denies and tracks it like an ancillary charge. Telemedicine policy is in Section I and the billing protocol is in Section III. Those sections weren't summarized here, so check how they interact with the encounter.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "212.400; 262.120 Telemedicine (eff. 2-1-22)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - Section I telemedicine policy not reviewed",
    "id": "AR-107",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Rate setting / PPS",
    "codes": "",
    "question": "How are Arkansas FQHC PPS rates calculated?",
    "answer": "PPS has applied since January 1, 2001. The base per-encounter rate is total audited allowable costs from the 1999 and 2000 cost reports, divided by total audited encounters, with MEI adjustments. FQHCs without at least 6 months in 1999 or 2000, or that enrolled after 2000, start at the average rate of the three nearest similar FQHCs by map mileage. A final rate is then set from their first two audited cost reports.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "252.000; 252.100; 252.110 Calculation of PPS Per Encounter Rate",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-108",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Alternative payment method (APM)",
    "codes": "",
    "question": "What is Arkansas's alternative FQHC payment method?",
    "answer": "FQHCs can sign a written agreement for the alternative method. They get an interim per-encounter rate, then a cost settlement at the greater of 100% of reasonable costs (Medicare principles, 42 CFR 413) or the PPS amount. You can ask to lower your interim rate: by up to 20% of the January 1, 2001 rate, or up to 10% for later rates. Send a written request within 21 days of the rate notice.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "252.200; 252.210; 252.211 Provider-Initiated PPS Rate Reductions",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-109",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "What counts as a change in scope of services for Arkansas FQHCs?",
    "answer": "The PPS rate is adjusted up or down for:\n- adding or dropping an FQHC service, such as dental or mental health\n- changes in the magnitude, intensity or character of services, such as adding specialists or HIV services\n- new state or federal regulatory requirements\n- relocation, remodeling, or opening or closing a site\n- changes in technology or medical practice\n- recurring taxes, malpractice or workers' comp premiums that weren't in the base year",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "252.120 / 252.220 Rate Adjustments for Scope of Services Changes",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-110",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "CMS-222-92",
    "question": "When is the Arkansas FQHC cost report due?",
    "answer": "File form CMS-222-92 with the DMS Financial Activities Unit within 5 months after the cost reporting period ends. Medicaid suspends payment if it's late. An extension needs a written request at least 10 working days before the due date, with evidence of circumstances beyond your control. Payment isn't suspended if you meet the extended date.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "253.000 Filing Cost Report Form CMS-222-92",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-111",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Rate and settlement appeals",
    "codes": "",
    "question": "How does an Arkansas FQHC appeal its rate or cost settlement?",
    "answer": "Send a written reconsideration request to the DMS Assistant Director within 20 calendar days of the policy action or rate notice. You can ask for a conference. The Division responds within 20 calendar days of the request or the conference. If you're still not satisfied, you can appeal to the standing Rate Review Panel.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "255.000 Rate Appeal and/or Cost Settlement Appeal Process",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-112",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Family planning and OB",
    "codes": "",
    "question": "How do Arkansas FQHCs handle OB/GYN procedures and family planning?",
    "answer": "FQHCs may report five OB/GYN surgeries by CPT code instead of the encounter code. These count as core encounters only when calculating cost per encounter. Family planning visits (basic, periodic and post-sterilization), contraceptives and sterilizations have their own coverage rules and benefit limits, which don't count toward the FQHC limit. Federal sterilization consent rules apply.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "215.000; 216.000-216.410; 220.100",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-113",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "MAT billing",
    "codes": "",
    "question": "Anything special when billing MAT encounters in Arkansas?",
    "answer": "Yes. Put the actual rendering provider's NPI on the claim. The claim is denied if the billing provider's number is used. MAT for OUD as the primary diagnosis doesn't count against the encounter limit.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "262.430 Medication Assisted Treatment (eff. 9-1-20); 220.000 B.5",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-114",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Sites / satellite clinics",
    "codes": "",
    "question": "Does each Arkansas FQHC site need its own Medicaid enrollment?",
    "answer": "Yes. Each clinic enrolls separately and gets its own provider number linked to the center's EIN, and bills only for its own services. FQHCs must be located in Arkansas and send their PHS (Section 330) Notice of Grant Award every grant year. Other ambulatory services, such as dental, are billed under that program's rules and provider number at fee schedule (the lesser of billed charge or the Medicaid maximum).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Federally Qualified Health Center (FQHC) Section II (DHS Division of Medical Services, FQHC_II.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/FQHC_II.docx",
    "source_section": "201.000; 201.100; 262.424",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-115",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas Medicaid fee-for-service (DHS Division of Medical Services)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing",
    "codes": "",
    "question": "What is Arkansas Medicaid's timely filing limit?",
    "answer": "12 months from the beginning date of service (42 CFR 447.45(d)(1)). For dual eligibles, filing with Medicare within 12 months meets timely filing, and Medicaid can pay within 6 months after the Medicare decision. Claims more than 12 months past can't be sent electronically. Resubmissions after 12 months must meet the clean-claim and new-claim tests and use form AR-004 or the listed procedures.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Arkansas Medicaid Provider Manual - Section III: Billing Procedures (all providers, Section_III.docx)",
    "source_url": "https://humanservices.arkansas.gov/wp-content/uploads/Section_III.docx",
    "source_section": "302.000 Timely Filing; 302.500",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "AR-116",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas PASSE managed care (Provider-Led Arkansas Shared Savings Entities)",
    "payer_type": "Managed Medicaid",
    "category": "Managed care overview",
    "codes": "",
    "question": "Does Arkansas Medicaid use managed care for FQHC patients?",
    "answer": "Only for a limited group. Arkansas's risk-based managed care is the PASSE program. It covers beneficiaries with complex behavioral health or intellectual/developmental disability needs: those on the CES waiver or its waitlist, those with a BH diagnosis needing more than counseling or medication management, those with an Independent Assessment of Tier 2 or higher, and residents of private ICF/IID facilities. PASSEs manage most Medicaid services for these members, including physical health. The PASSEs listed are Arkansas Total Care, CareSource, Empower and Summit. Most other Medicaid members are billed fee-for-service under the FQHC manual.",
    "claim_format": "-",
    "source_title": "Arkansas DHS - PASSE (Provider-Led Arkansas Shared Savings Entity) program page",
    "source_url": "https://humanservices.arkansas.gov/divisions-shared-services/medical-services/healthcare-programs/passe/",
    "source_section": "Program overview and eligibility sections",
    "last_verified": "2026-10-30",
    "confidence": "Medium - from DHS program page; PASSE FQHC payment terms not reviewed",
    "id": "AR-117",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Arkansas",
    "payer": "Arkansas PASSE managed care (Provider-Led Arkansas Shared Savings Entities)",
    "payer_type": "Managed Medicaid",
    "category": "PASSE billing and FQHC payment",
    "codes": "",
    "question": "How are FQHCs paid for PASSE members in Arkansas?",
    "answer": "Not verified. The FQHC Section II manual doesn't cover PASSE billing or a state wraparound or reconciliation for PASSE members. Check the PASSE provider manuals and contracts (Arkansas Total Care, CareSource, Empower, Summit) before billing.",
    "claim_format": "-",
    "source_title": "Arkansas DHS - PASSE (Provider-Led Arkansas Shared Savings Entity) program page",
    "source_url": "https://humanservices.arkansas.gov/divisions-shared-services/medical-services/healthcare-programs/passe/",
    "source_section": "n/a",
    "last_verified": "2026-10-30",
    "confidence": "Low - unverified; marked as a gap",
    "id": "AR-118",
    "region": "Region 6",
    "state_abbr": "AR"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "T1015",
    "question": "How do I get reimbursed for office visits for Oklahoma SoonerCare?",
    "answer": "OHCA pays a facility-specific PPS rate per encounter (BIPA 2000 Section 702), set under Attachment 4.19-B of the State Plan. An encounter is a face-to-face contact between an authorized health care professional and a member within a 24-hour period ending at midnight, documented in the record. Only professionals listed in the approved FQHC State Plan pages trigger the PPS rate. Covered encounter types include medical, diagnostic, dental, medical and BH screenings, optometry, PT, OT, podiatry, BH, speech and hearing. The encounter is billed with procedure code T1015 (see the same-day and telehealth notices).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.3, FQHC encounters (revised 09-01-26)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/federally-qualified-health-center-fqhc-encounters.html",
    "source_section": "317:30-5-664.3(a)-(d); also OAC 317:30-5-664.10(a) and PRN 2020-08",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-119",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "T1015-XE",
    "question": "Can an Oklahoma FQHC bill more than one encounter on the same day?",
    "answer": "Normally one encounter per 24 hours. Visits with more than one FQHC practitioner on the same day count as one visit. Exceptions: a later illness or injury needing more diagnosis or treatment, or a qualified medical visit plus a qualified mental health and/or dental visit on the same day. Each encounter needs a distinctly different diagnosis, and centers can't set up routines that create multiple encounters. To bill the additional same-day encounter, add modifier XE to T1015. Medical review is required for additional visits for children.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA Provider Reimbursement Notice PRN 2020-08, FQHC Same Day Encounters (Sept 28, 2020)",
    "source_url": "https://oklahoma.gov/content/dam/ok/en/okhca/documents/a0302/25144.pdf",
    "source_section": "PRN 2020-08 (p.1); OAC 317:30-5-664.4 and 664.3(c)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "OK-120",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Lab, supplies and drugs",
    "codes": "",
    "question": "What is excluded from the Oklahoma FQHC encounter?",
    "answer": "Excluded from the encounter: labs by an independent CLIA lab; radiology, including nuclear medicine and diagnostic ultrasound; administrative exams; emergency services for non-qualified (ineligible) members; SoonerPlan family planning; DSMES; and medical supplies not usually provided during a visit, such as diabetic supplies. Venipuncture is part of the encounter, and a lab-only visit isn't an encounter (bill the appropriate CPT code). Drugs given during the visit are included in the encounter. Prescriptions are billed through the pharmacy program.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.5, FQHC encounter exclusions and limitations (revised 09-01-26)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/health-center-encounter-exclusions-and-limitations.html",
    "source_section": "317:30-5-664.5(a)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-121",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "LARC / family planning",
    "codes": "",
    "question": "Are LARC devices paid outside the Oklahoma FQHC encounter rate?",
    "answer": "Yes. Long-acting reversible contraceptive devices aren't part of the FQHC encounter rate and can be billed separately. Family planning for SoonerCare Traditional and Choice members is a Health Center core service. SoonerPlan (the family-planning-only benefit) is excluded from the encounter definition.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.5, FQHC encounter exclusions and limitations (revised 09-01-26)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/health-center-encounter-exclusions-and-limitations.html",
    "source_section": "317:30-5-664.5(a)(9)-(10); OAC 317:30-5-664.9",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-122",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth / virtual",
    "codes": "T1015-GT; audio-only paid FFS",
    "question": "Does Oklahoma pay the FQHC encounter rate for telehealth?",
    "answer": "Audio-only services don't count as an encounter. They're paid at the SoonerCare fee-for-service rate, including audio-only BH. The 2020 PRN told FQHCs to bill audio-video telehealth with T1015 plus modifier GT on line 1 and the E/M code on line 2; the first line pays the encounter rate. That PRN was issued during COVID and some of the telephone codes it lists have since been retired, so check current OHCA guidance before relying on its line setup.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.10, Health Center reimbursement (revised 09-01-24)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/health-center-reimbursement.html",
    "source_section": "317:30-5-664.10(b)-(c) and 664.3(b) (current rules); PRN 2020-02 (p.1) for the line setup",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the audio-only rule is in current OHCA rules; the T1015-GT setup comes from a 2020 COVID-era notice.",
    "id": "OK-123",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health",
    "codes": "",
    "question": "How are behavioral health services paid at an Oklahoma FQHC?",
    "answer": "Primary and preventive BH services from professionals authorized in the FQHC State Plan pages are paid at the PPS encounter rate, except audio-only, which is paid FFS. To bill the PPS rate, a one-on-one standard clinical session must be completed by an authorized professional. Services from providers who aren't authorized are paid from the SoonerCare fee schedule. Bill with the appropriate CPT code; the time on the claim must be time actually spent with the member. BH services may be delivered away from the center in a confidential setting. BH case management and psychosocial rehab require enrollment and an OHCA contract as an outpatient BH agency.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-661.4, Behavioral health professional services provided at Health Centers (revised 09-01-17)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/behavioral-health-professional-services-provided-at-health-centers-and-other-settings.html",
    "source_section": "317:30-5-661.4(a)-(e); 664.10(c); 664.5(b)(2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-124",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "ADA claim form",
    "question": "How does an Oklahoma FQHC bill dental services?",
    "answer": "Dental claims must go on the ADA claim form. For adults, the core dental benefit covers immediate treatment, pain relief or extraction (for example acute infection, abscess, severe tooth pain, re-implantation), not restoration. Medically necessary dental for members under 21 is covered. Dental services that aren't core services are billed using the SoonerCare fee schedule.",
    "claim_format": "ADA dental claim",
    "source_title": "OHCA rule OAC 317:30-5-664.7, Dental services provided by Health Centers (revised 09-01-21)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/dental-services-provided-by-health-centers.html",
    "source_section": "317:30-5-664.7(a)-(d)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-125",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Prenatal / OB",
    "codes": "",
    "question": "How do Oklahoma FQHCs bill prenatal care and deliveries?",
    "answer": "The center must have a written agreement with its physician, CNM, APRN or PA that spells out how OB care is billed. If the center pays the provider for OB care, the center bills each prenatal and postpartum visit separately with the appropriate E/M code. If it doesn't, the provider bills prenatal care with the global method under the physician rules (OAC 317:30-5-22). Deliveries are billed with delivery CPT codes; if the center doesn't pay the provider, the provider bills under their own number, and delivery costs are left out of cost settlement and rate setting.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.8, Obstetrical care provided by Health Centers (revised 09-01-19)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/obstetrical-care-provided-by-health-centers.html",
    "source_section": "317:30-5-664.8(a)-(c)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-126",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services away from the center",
    "codes": "",
    "question": "Can an Oklahoma FQHC bill for services provided off-site?",
    "answer": "Yes, when the center bills them and the practitioner's agreement says they must seek payment from the center. Off-site services include mobile clinics and school settings where the school has no OHCA contract and parental authorization is on file. The center needs a written contract with the practitioner that says off-site services will be billed to Medicaid and how the practitioner is paid. Off-site services are expected to be temporary and intermittent. Physician services in a hospital aren't covered as FQHC services.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-661.7, Off-site services (revised 06-25-07)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/off-site-services.html",
    "source_section": "317:30-5-661.7(a)-(b); 664.5(b)(1)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-127",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate / annual update",
    "codes": "",
    "question": "How is the Oklahoma FQHC PPS rate updated each year?",
    "answer": "OHCA updates each center's PPS encounter rate every July 1 by the Medicare Economic Index (MEI). For example, PRN 2024-04 raised SFY 2025 rates by 3.30% over SFY 2024 for dates of service on or after July 1, 2024. Check OHCA's latest PRN for the current year's update. Rates are facility-specific; this site doesn't list them.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA Provider Reimbursement Notice PRN 2024-04, Annual FQHC and RHC Rate Update (July 1, 2024)",
    "source_url": "https://oklahoma.gov/content/dam/ok/en/okhca/docs/providers/claim-tools/provider-reimbursement-notices/2024/24-04%20Annual%20FQHC%20and%20RHC%20rate%20update.pdf",
    "source_section": "PRN 2024-04 (p.1); OAC 317:30-5-664.12(a)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "OK-128",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How does an Oklahoma FQHC request a change in scope rate adjustment?",
    "answer": "If a center significantly changes its scope of services, it may ask OHCA in writing to set new baseline encounter rates. It's the FQHC's job to request the review. OHCA may also start an adjustment itself, based on audited financials or cost reports. A new rate takes effect on the date the change in scope was implemented.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.12, Determination of Health Center PPS rate (revised 09-01-15)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/determination-of-health-center-pps-rate.html",
    "source_section": "317:30-5-664.12(b)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-129",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "",
    "question": "Do Oklahoma FQHCs file a Medicaid cost report?",
    "answer": "Yes. Every center seeking SoonerCare payment files an annual report, in an OHCA-prescribed format, covering 12 months of operations. Centers with several sites must file it too. The center picks its reporting period, subject to OHCA approval, and can change it only with written OHCA authorization. OHCA can use the report to adjust payment for a change in scope and may contract for independent audits.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.15, Health Center cost reporting (issued 06-07-06)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/health-center-cost-reporting.html",
    "source_section": "317:30-5-664.15(a)-(f)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-130",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Wraparound / reconciliation",
    "codes": "",
    "question": "Does Oklahoma reconcile FQHC payments to the PPS rate?",
    "answer": "Yes. OHCA makes PPS reconciliation (wraparound) adjustments for the difference between the facility-specific PPS rate and the fee-schedule payments made, such as audio-only and non-authorized BH services paid FFS. Reconciliation happens at least quarterly. The rule doesn't describe a SoonerSelect-specific wrap process, so confirm it with OHCA.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.11, PPS rate reconciliation to Health Centers (revised 06-25-07)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/pps-rate-reconciliation-to-health-centers.html",
    "source_section": "317:30-5-664.11(a)-(c)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - rule text is clear for FFS; how it applies to SoonerSelect isn't stated.",
    "id": "OK-131",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerCare (OHCA fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossovers",
    "codes": "",
    "question": "How does Oklahoma pay FQHC claims for members who also have Medicare Part B?",
    "answer": "For members eligible for Medicare Part B, payment uses the SoonerCare allowable for comparable services. Dual eligibles are excluded from SoonerSelect and stay in their current SoonerCare program.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA rule OAC 317:30-5-664.13, Individuals eligible for Part B of Medicare (issued 06-07-06)",
    "source_url": "https://oklahoma.gov/ohca/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/federally-qualified-health-centers/individuals-eligible-for-part-b-of-medicare.html",
    "source_section": "317:30-5-664.13; SoonerSelect excluded populations",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in the official OHCA rules page, which OHCA labels unofficial (the official text is OAC Title 317 from the Oklahoma Secretary of State).",
    "id": "OK-132",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerSelect (Aetna Better Health of OK, Humana Healthy Horizons in OK, Oklahoma Complete Health)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / MCO overview",
    "codes": "",
    "question": "Does Oklahoma use managed care MCOs for Medicaid?",
    "answer": "Yes. SoonerSelect health plans are Aetna Better Health of Oklahoma, Humana Healthy Horizons of Oklahoma and Oklahoma Complete Health. Oklahoma Complete Health also runs the Children's Specialty Program for children in Child Welfare custody, juvenile-justice-involved youth, and former foster youth. Dental plans are DentaQuest and Liberty Dental. Children, low-income adults, pregnant women and non-disabled adults 19-64 must enroll. Dual eligibles, ABD members (including TEFRA), 1915(c) waiver members, NF/ICF-IID level of care and some others are excluded and stay in SoonerCare FFS. AI/AN members can opt in.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA - SoonerSelect program page (health plans, dental plans, mandatory and excluded populations)",
    "source_url": "https://oklahoma.gov/ohca/soonerselect.html",
    "source_section": "SoonerSelect Health; Dental Plans; Children's Specialty Program; Mandatory and Excluded Populations",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "OK-133",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerSelect (Aetna Better Health of OK, Humana Healthy Horizons in OK, Oklahoma Complete Health)",
    "payer_type": "Managed Medicaid",
    "category": "Network / contracting",
    "codes": "",
    "question": "Must Oklahoma SoonerSelect plans contract with FQHCs?",
    "answer": "SoonerSelect plans can't exclude essential community providers, and FQHCs and RHCs are on that list. If a plan pays an out-of-network provider, the default floor is at least 90% of the Medicaid fee schedule. That floor doesn't apply to FQHCs, RHCs, IHCPs and CCBHCs, which are paid under other rules. Each plan must also contract with at least one local Oklahoma provider organization, and an FQHC can be one.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "OHCA - SoonerSelect Provider FAQs",
    "source_url": "https://oklahoma.gov/ohca/soonerselect/provider-resources/faqs.html",
    "source_section": "FAQ: 'Are CEs required to contract with any willing provider?'; OAC 317:55-5-22(b)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited sources (the plan payment amount for FQHCs isn't stated there).",
    "id": "OK-134",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerSelect (Aetna Better Health of OK, Humana Healthy Horizons in OK, Oklahoma Complete Health)",
    "payer_type": "Managed Medicaid",
    "category": "Claim form / submission",
    "codes": "T1015",
    "question": "How do I bill an FQHC encounter to Oklahoma Complete Health (SoonerSelect)?",
    "answer": "FQHCs bill Oklahoma Complete Health on a CMS-1500, with the appropriate encounter code plus CPT codes for core services. For non-core services only, bill only the CPT code; it pays from the fee schedule. (RHCs bill on the UB-04.) Aetna and Humana publish their own manuals, which aren't summarized here yet.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Oklahoma Complete Health - 2026 Provider Billing Manual (SoonerSelect; Caid_SSP...260317)",
    "source_url": "https://www.oklahomacompletehealth.com/content/dam/centene/oklahoma-complete-health/pdfs/Provider%20Manual/English/2026/SSP/2026%20Provider%20Billing%20Manual_Approved_R.pdf",
    "source_section": "Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) (p.35-36)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "OK-135",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Oklahoma",
    "payer": "SoonerSelect (Aetna Better Health of OK, Humana Healthy Horizons in OK, Oklahoma Complete Health)",
    "payer_type": "Managed Medicaid",
    "category": "Timely filing",
    "codes": "",
    "question": "What is the timely filing limit for Oklahoma Complete Health claims?",
    "answer": "First-time claims are due within 180 calendar days of the date of service, with a limited exception when filing on time wasn't reasonably possible (never later than 365 days). Written claim adjustments are due within 180 days of the EOP or ERA; claims aren't adjusted 365 days or more after the date of service. Appeals are due within 60 calendar days of the EOP or ERA.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Oklahoma Complete Health - 2026 Provider Billing Manual (SoonerSelect; Caid_SSP...260317)",
    "source_url": "https://www.oklahomacompletehealth.com/content/dam/centene/oklahoma-complete-health/pdfs/Provider%20Manual/English/2026/SSP/2026%20Provider%20Billing%20Manual_Approved_R.pdf",
    "source_section": "Timely Filing (p.15-16)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "OK-136",
    "region": "Region 6",
    "state_abbr": "OK"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "T1015",
    "question": "How do I get reimbursed for office visits for Iowa Medicaid?",
    "answer": "Under FFS, Iowa pays FQHCs the greater of 100% of reasonable Medicaid costs for the encounter or the provider-specific BIPA PPS rate. Bill T1015 on the first line for every FQHC medical encounter, whatever the underlying services. The encounter rate is all-inclusive for that member and date of service.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa Medicaid Billing Guidance Update - FQHC/RHC Medicaid Reimbursement and Wraparound Payments (effective October 1, 2026)",
    "source_url": "https://hhs.iowa.gov/media/19535/download?inline=",
    "source_section": "FQHC/RHC Medicaid Reimbursement (p.1); see also IAM Ch. III.E (p.61)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-137",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "CMS-1500; T1015",
    "question": "Which claim form and line structure does an Iowa FQHC use?",
    "answer": "The CMS-1500. T1015 goes on line 1. Every following line lists the specific procedure codes for the services actually given, billed at $0.00 as informational only. Claims without those detail lines are denied. Iowa Medicaid edits for prior authorization where a service needs it.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa HHS - Federally Qualified Health Center (FQHC) Provider Manual, Chapter III (pages dated June 1, 2014 / July 1, 2015)",
    "source_url": "https://hhs.iowa.gov/media/4321/download",
    "source_section": "Ch. III.E Procedure Codes and Nomenclature (p.61); Ch. III.F Billing Policies (p.63); IAS (p.2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in Iowa HHS's currently posted FQHC manual, but its pages are dated 2014/2015; newer Iowa guidance is cited where it applies.",
    "id": "IA-138",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "T1015-59",
    "question": "Can an Iowa FQHC bill more than one encounter on the same day?",
    "answer": "Generally no. Seeing several practitioners, or the same practitioner more than once, on one day is one visit, regardless of length, complexity, scheduling, or whether the conditions are related. Exceptions: (1) the member leaves, then has a new illness or injury the same day, so add modifier 59 to T1015 (first modifier field, 24D) on the second medical visit; (2) a pharmacy encounter plus a medical encounter, with 59 on the second; (3) medical plus mental health, which are two encounters with no 59; (4) an IPPE plus a separate medical visit, with 59 on the second medical visit (not the MH visit); (5) psychotherapy and medication management on the same day, which are two encounters with no 59.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa Medicaid Informational Letter No. 2655-MC-FFS-D - Same Day Billing for FQHCs, RHCs and IHS (June 10, 2025)",
    "source_url": "https://secureapp.dhs.state.ia.us/IMPA/Information/ViewDocument.aspx?viewdocument=dbe98459-2851-49d9-8e18-14c1f7cf287d",
    "source_section": "Same Day Billing exemptions chart (p.1-3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-139",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "D9999; ADA claim form",
    "question": "How does an Iowa FQHC bill dental encounters?",
    "answer": "Bill dental on the ADA dental claim form, with D9999 on the first line; the claim denies without it. Don't use T1015 on dental claims. List the dental procedures on the following lines at $0.00, with tooth, surface or area of oral activity, and include the PA number when one is needed. Dental claims go to the member's dental plan. A dental encounter by a dentist or hygienist can be paid in addition to a same-day medical or mental health encounter, with no modifier 59.",
    "claim_format": "ADA dental claim",
    "source_title": "Iowa Medicaid Informational Letter No. 2655-MC-FFS-D - Same Day Billing for FQHCs, RHCs and IHS (June 10, 2025)",
    "source_url": "https://secureapp.dhs.state.ia.us/IMPA/Information/ViewDocument.aspx?viewdocument=dbe98459-2851-49d9-8e18-14c1f7cf287d",
    "source_section": "Dental Services same day (p.3-4); IAM Ch. III.E.1 Dental Services (p.62)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-140",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Modifiers",
    "codes": "U1, U6, EP, FP, U3, 32",
    "question": "Which modifiers does the Iowa FQHC manual list?",
    "answer": "The manual lists: U1 (Care for Kids screen with referral for treatment); U6 (EPSDT Care for Kids screen); EP (services resulting from a Care for Kids screen); FP (family planning-related service); U3 (medical expense services such as mental health diagnoses not covered by the former Iowa Plan); and 32 (annual routine physical required for an RCF resident). Modifier 59 for same-day exemptions comes from IL 2655.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa HHS - Federally Qualified Health Center (FQHC) Provider Manual, Chapter III (pages dated June 1, 2014 / July 1, 2015)",
    "source_url": "https://hhs.iowa.gov/media/4321/download",
    "source_section": "Ch. III.E Procedure Codes and Nomenclature - modifiers (p.62)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the manual pages date to 2014-2015 and the U3 Iowa Plan reference is outdated; confirm current modifier use.",
    "id": "IA-141",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "EPSDT / Care for Kids",
    "codes": "T1015; A0100",
    "question": "How does an Iowa FQHC bill EPSDT (Care for Kids) screenings?",
    "answer": "Bill the encounter code with the appropriate diagnosis code for the preventive visit. Agencies designated by the Department of Public Health use the encounter code with the CI modifier for EPSDT informing services, and A0100 for local medical transportation for children 20 and under. The manual lists V68.9 (an ICD-9 code) for these; use the current ICD-10 equivalent.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa HHS - Federally Qualified Health Center (FQHC) Provider Manual, Chapter III (pages dated June 1, 2014 / July 1, 2015)",
    "source_url": "https://hhs.iowa.gov/media/4321/download",
    "source_section": "Ch. III.E.2 EPSDT Care for Kids Services (p.62-63)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - manual text predates ICD-10; diagnosis code guidance is outdated.",
    "id": "IA-142",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report / settlement",
    "codes": "",
    "question": "Does Iowa cost-settle FQHCs?",
    "answer": "Yes. FFS payment is based on 100% of reasonable costs determined from the FQHC cost report under Medicare cost principles, with interim per-visit rates reconciled after the report. Iowa Medicaid pays any underpayment within 90 days of receiving the cost report, and the FQHC repays any overpayment within 90 days of notice. Medicaid cost reports are due five months after fiscal year end. MCO wraparound payments are also cost-settled.",
    "claim_format": "n/a",
    "source_title": "Iowa HHS - Federally Qualified Health Center (FQHC) Provider Manual, Chapter III (pages dated June 1, 2014 / July 1, 2015)",
    "source_url": "https://hhs.iowa.gov/media/4321/download",
    "source_section": "Ch. III.D Basis of Payment (p.58-59); IAW (p.2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - read in Iowa HHS's currently posted FQHC manual, but its pages are dated 2014/2015; newer Iowa guidance is cited where it applies.",
    "id": "IA-143",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "Iowa Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Practitioners",
    "codes": "",
    "question": "Which practitioners' services are covered at an Iowa FQHC?",
    "answer": "Physician services, plus services of PAs and NPs (whether or not a physician directs the center full-time), clinical psychologists and clinical social workers. Incident-to services and supplies are covered when furnished by a center employee under the direct supervision of an NP, PA or physician, and are of a type commonly furnished in a physician's office and included in the center's bill. Pharmacy encounters are addressed separately (IL 1908 and IL 2545, not reviewed).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa HHS - Federally Qualified Health Center (FQHC) Provider Manual, Chapter III (pages dated June 1, 2014 / July 1, 2015)",
    "source_url": "https://hhs.iowa.gov/media/4321/download",
    "source_section": "Ch. III.C.13 Services of Other Practitioners (p.57-58); IAS (p.2)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - manual is dated 2014; pharmacy encounter ILs not reviewed.",
    "id": "IA-144",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "IA Health Link MCOs (Iowa Total Care, Molina Healthcare of Iowa, Wellpoint Iowa)",
    "payer_type": "Managed Medicaid",
    "category": "Managed care overview",
    "codes": "",
    "question": "Which MCOs pay Iowa FQHCs, and what is the payment floor?",
    "answer": "IA Health Link MCOs are Iowa Total Care (ITC), Molina Healthcare of Iowa (MHC) and Wellpoint Iowa (WLP). Dental plans are MCNA Dental, DentaQuest and Delta Dental. When an FQHC contracts with an MCO, Iowa Medicaid supplements the MCO payment so the FQHC gets at least what PPS would pay. Under IL 1562, the managed care rate floor is the provider-specific BIPA PPS rate, updated each year.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa Medicaid Billing Guidance Update - FQHC/RHC Medicaid Reimbursement and Wraparound Payments (effective October 1, 2026)",
    "source_url": "https://hhs.iowa.gov/media/19535/download?inline=",
    "source_section": "FQHC/RHC Medicaid Reimbursement (p.1); field 11 MCO list (p.3); IAS contacts (p.4-5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-145",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "IA Health Link MCOs (Iowa Total Care, Molina Healthcare of Iowa, Wellpoint Iowa)",
    "payer_type": "Managed Medicaid",
    "category": "Wraparound payments",
    "codes": "Form 470-3495; Form 470-5419",
    "question": "How does an Iowa FQHC request an MCO wraparound payment?",
    "answer": "No request is needed if the MCO paid more than the reasonable cost per encounter from the latest settled cost report; if it paid less, the FQHC may request a wraparound. File by calendar quarter, within 60 days after quarter end. Submit one signed Wraparound Payment Request (470-3495, PDF) covering all MCOs, plus Supporting Claims Detail (470-5419, Excel), through the IMPA secure upload. First-time users file the access form 470-5479. If an extenuating circumstance causes a late filing, email Provider Cost Audit (costaudit@hhs.iowa.gov); late requests are accepted up to the date that period's cost report is filed.",
    "claim_format": "Forms 470-3495 / 470-5419 via IMPA",
    "source_title": "Iowa Medicaid Billing Guidance Update - FQHC/RHC Medicaid Reimbursement and Wraparound Payments (effective October 1, 2026)",
    "source_url": "https://hhs.iowa.gov/media/19535/download?inline=",
    "source_section": "Wraparound Requests; Quarterly Submission (p.1-5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-146",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "IA Health Link MCOs (Iowa Total Care, Molina Healthcare of Iowa, Wellpoint Iowa)",
    "payer_type": "Managed Medicaid",
    "category": "Wraparound - eligible claims",
    "codes": "T1015",
    "question": "Which MCO claims can go on an Iowa wraparound request?",
    "answer": "Only Iowa Medicaid Title XIX and Wellness claims paid during the quarter, billed with T1015, and paid correctly by the MCO. Exclude hawk-i funded services, dates the member wasn't on Iowa Medicaid, interest, Health Home payments, zero-pay claims where Medicaid is primary, and Medicare crossovers. Report the state Medicaid ID, not the MCO ID. If a claim has more than 10 codes, report T1015 plus the next 9. The provider must compile the data, since it won't be pulled from the MCOs.",
    "claim_format": "Form 470-5419",
    "source_title": "Iowa Medicaid Billing Guidance Update - FQHC/RHC Medicaid Reimbursement and Wraparound Payments (effective October 1, 2026)",
    "source_url": "https://hhs.iowa.gov/media/19535/download?inline=",
    "source_section": "Required Data; What to Include/Exclude (p.2-3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-147",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "IA Health Link MCOs (Iowa Total Care, Molina Healthcare of Iowa, Wellpoint Iowa)",
    "payer_type": "Managed Medicaid",
    "category": "Same-day billing (MCO)",
    "codes": "T1015-59",
    "question": "Do Iowa's same-day FQHC billing rules apply to MCO claims?",
    "answer": "Yes. IL 2655-MC-FFS-D applies to managed care, FFS and dental, and has been sent to the MCOs. T1015 goes on line 1 with $0.00 informational detail lines, and modifier 59 on the T1015 line marks the allowed exemptions. Contact the MCO for plan-specific questions: Iowa Total Care 1-833-404-1061; Molina 1-844-236-1464; Wellpoint 1-833-731-2143.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Iowa Medicaid Informational Letter No. 2655-MC-FFS-D - Same Day Billing for FQHCs, RHCs and IHS (June 10, 2025)",
    "source_url": "https://secureapp.dhs.state.ia.us/IMPA/Information/ViewDocument.aspx?viewdocument=dbe98459-2851-49d9-8e18-14c1f7cf287d",
    "source_section": "Applies To; reminder; MCO contacts (p.1-5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "IA-148",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Iowa",
    "payer": "IA Health Link MCOs (Iowa Total Care, Molina Healthcare of Iowa, Wellpoint Iowa)",
    "payer_type": "Managed Medicaid",
    "category": "Dental plan wraparound",
    "codes": "Form 470-5210",
    "question": "Is there a wraparound for dental plan payments to Iowa FQHCs?",
    "answer": "Yes. The dental plan must pay the FQHC at least what it pays other providers, and Iowa Medicaid supplements to reasonable cost. The manual names form 470-5210 (Dental Wellness Plan Wraparound Payment Request), due within 30 days of quarter end. The 2026 guidance lists dental plans (MCNA, DentaQuest, Delta Dental) as MCO codes on form 470-5419 instead.",
    "claim_format": "Form 470-5210 / 470-5419",
    "source_title": "Iowa HHS - Federally Qualified Health Center (FQHC) Provider Manual, Chapter III (pages dated June 1, 2014 / July 1, 2015)",
    "source_url": "https://hhs.iowa.gov/media/4321/download",
    "source_section": "Ch. III.D.2 Dental Wellness Plan Wraparound (p.60); IAW field 11 (p.3)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the 2014 manual and 2026 guidance differ on forms; follow the 2026 guidance and the HHS website.",
    "id": "IA-149",
    "region": "Region 7",
    "state_abbr": "IA"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Payment methodology",
    "codes": "",
    "question": "How does MO HealthNet pay FQHCs - PPS per visit or cost?",
    "answer": "Missouri pays FQHCs on a cost basis, not a per-visit PPS rate. MHD reimburses the reasonable cost of FQHC-covered services, less participant copays and deductibles. Reasonable cost can't exceed Medicare cost principles (42 CFR 413) and is shared out to Medicaid by the ratio of Medicaid charges (including managed care) to total charges. During the year, FFS claims get interim payments of up to 92% of charges for covered services. A final settlement then reconciles the interim payments to allowable cost from the cost report.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(2)(A)-(C), (4)(A), (5)(A) (pp.3-5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-150",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / office visits",
    "codes": "CMS-1500",
    "question": "What claim form do Missouri FQHCs use for MO HealthNet FFS?",
    "answer": "MHD's FQHC telehealth bulletin tells FQHCs to leave the CMS-1500 rendering provider field (24J) blank when billing Q3014, which shows FQHC FFS claims go on the professional claim format. Interim payment depends on billed charges, so bill your usual charges; MHD pays the lower of billed charge or the maximum allowed. No FQHC-specific MHD provider manual turned up on the current provider-manual index. Check claim details with MHD Provider Communications (573-751-2896).",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "MO HealthNet Provider Bulletin Vol. 41 No. 44 - Revised Telehealth Originating Site Reimbursement for RHCs and FQHCs",
    "source_url": "https://dss.mo.gov/sites/mydss/files/media/pdf/2023/08/Revised_Telehealth_Originating_Site_Reimbursement_for_Rural_Health_Clinics_and_Federally_Qualified_Health_Centers_Vol41-No44.pdf",
    "source_section": "Bulletin Vol. 41 No. 44, p.1",
    "last_verified": "2026-10-30",
    "confidence": "Low - inferred from a bulletin; no current FQHC-specific MHD manual found on the public index.",
    "id": "MO-151",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Covered FQHC services",
    "codes": "",
    "question": "What services are covered as FQHC services by MO HealthNet?",
    "answer": "Core services under SSA 1861(aa)(1)(A)-(C): physician services and incident-to supplies (including drugs that can't be self-administered), pneumococcal and flu vaccines and their administration, PA, NP, clinical psychologist and clinical social worker services, and part-time home nursing in areas short of home health agencies. Also covered: section 330 preventive primary care services (42 CFR 405.2448) and any other Title XIX ambulatory services the FQHC chooses to provide.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "MO HealthNet - Federally Qualified Health Center and Rural Health Clinic Services (covered services table, reviewed Jan 2016)",
    "source_url": "https://dss.mo.gov/sites/mydss/files/media/pdf/2023/12/2017-fqhc-rhc-services.pdf",
    "source_section": "Covered services table, p.1 (reviewed Jan 2016)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - official but older reference document",
    "id": "MO-152",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "",
    "question": "When is the Missouri Medicaid FQHC cost report due?",
    "answer": "Within 5 months after the end of the FQHC's reporting period. Extension requests must be in writing and postmarked before the first day of the 6th month after fiscal year end. An officer or administrator must certify the report. Required attachments include audited financials, related-party contracts, the grants schedule, leases, management contracts and the working trial balance. Late filing can bring sanctions under 13 CSR 70-3.030. Requested information is due within 14 days, or payments may be withheld.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(2)(D)-(F), (5)(C) (pp.3-4)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-153",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report exemption",
    "codes": "",
    "question": "Can a Missouri FQHC skip the Medicaid cost report?",
    "answer": "Yes, if MO HealthNet reimbursement was $25,000 or less for the reporting period. Within 5 calendar months after the period closes, send the Low or No Missouri Medicaid Utilization Waiver Request Form and the Medicare cost report Worksheet S series, both signed by an officer or administrator.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(2)(D)1 (p.3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-154",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Nonallowable costs / grants",
    "codes": "",
    "question": "Are HRSA grants offset against costs on the Missouri FQHC cost report?",
    "answer": "Grants, gifts and endowment income are generally deducted from operating costs. Exceptions include federal grants such as HRSA awards, MPCA contractual grants, grants for uninsured patient services reported on Worksheet 2, EHR meaningful-use incentives, and MHD Medical Home payments. Also nonallowable: bad debts, charity and courtesy allowances, return on equity, some attorney fees, late charges and penalties, and research costs.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(3) (p.4)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-155",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Final settlement",
    "codes": "",
    "question": "How does Missouri's FQHC final settlement work?",
    "answer": "MHD desk-reviews each cost report. If allowable Medicaid cost is more than interim payments, MHD pays a lump sum; if less, the FQHC repays by offset, by check or both. The FQHC has 15 calendar days from the settlement letter to return a signed Settlement Agreement or send corrected data. After that, the settlement is final, and amended cost reports aren't accepted once it's finalized. Field audits can adjust the result.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(5)(A)-(D) (pp.4-5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-156",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth / virtual",
    "codes": "Q3014",
    "question": "How do Missouri FQHCs bill telehealth to MO HealthNet FFS?",
    "answer": "As the originating site, bill Q3014 and leave the CMS-1500 rendering provider field (24J) blank. MHD pays the lower of billed charge or the maximum allowed amount. Take telehealth charges and payments off the year-end cost report. For managed care members, contact the MCO.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "MO HealthNet Provider Bulletin Vol. 41 No. 44 - Revised Telehealth Originating Site Reimbursement for RHCs and FQHCs",
    "source_url": "https://dss.mo.gov/sites/mydss/files/media/pdf/2023/08/Revised_Telehealth_Originating_Site_Reimbursement_for_Rural_Health_Clinics_and_Federally_Qualified_Health_Centers_Vol41-No44.pdf",
    "source_section": "Bulletin Vol. 41 No. 44, p.1",
    "last_verified": "2026-10-30",
    "confidence": "Medium - 2018/2019 bulletin; confirm against current MHD telehealth policy and the fee schedule",
    "id": "MO-157",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing",
    "codes": "",
    "question": "What is the MO HealthNet timely filing limit?",
    "answer": "MHD must receive the claim within 12 months from the date of service. Claims filed with Medicare first are due by 12 months from the date of service or 6 months from the Medicare notice, whichever is later. A claim filed on time and then denied or returned can be resubmitted or adjusted up to 24 months from the date of service, using eMOMED's Timely Filing function.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "MO HealthNet General Sections Provider Manual (published 03/2026, DOCX)",
    "source_url": "https://dss.mo.gov/sites/mydss/files/media/file/2026/03/General-Sections-Provider-Manual.docx",
    "source_section": "Section 4.1 Timely Filing Dates and Limits; Section 6 Timely Filing (eMOMED)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-158",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossovers / TPL",
    "codes": "",
    "question": "How does MO HealthNet pay FQHC services for Medicare or other-insured patients?",
    "answer": "For patients with Medicare, MO HealthNet pays up to the Title XVIII coinsurance and deductible. MO HealthNet pays last, so bill other insurance first, within MHD timely filing limits. A late response from the other insurer doesn't extend those limits; contact the TPL Unit before the 12 months run out.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(6)(B)-(C) (p.5); General Sections Manual Section 4.1 / 5",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-159",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet fee-for-service (MHD)",
    "payer_type": "Medicaid FFS",
    "category": "Change of ownership",
    "codes": "",
    "question": "What happens to MO HealthNet FQHC payments after a change of ownership?",
    "answer": "MHD keeps paying the entity holding the FQHC's current provider number, and that entity is responsible for all MO HealthNet liabilities. After MHD learns of a termination or change of ownership, it can hold the next payment until the cost report is filed.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(2)(I), (6)(D) (pp.4-5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-160",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet Managed Care (Healthy Blue, Home State Health, UnitedHealthcare; Show Me Healthy Kids)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / MCO overview",
    "codes": "",
    "question": "Which MCOs run Missouri Medicaid managed care?",
    "answer": "MO HealthNet Managed Care plans are Healthy Blue, Home State Health and UnitedHealthcare Community Plan. Show Me Healthy Kids, run by Home State Health, is a separate plan for children in state care, and its members can't change plans. People with disabilities, those 65 and older, blind or visually impaired people and breast or cervical cancer enrollees are usually in MO HealthNet fee-for-service.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Missouri DSS - Contact Your Health Plan (MO HealthNet Managed Care plans)",
    "source_url": "https://dss.mo.gov/contact-health-plan",
    "source_section": "Contact Your Health Plan; How do I contact my Fee-For-Service health plan?",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-161",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet Managed Care (Healthy Blue, Home State Health, UnitedHealthcare; Show Me Healthy Kids)",
    "payer_type": "Managed Medicaid",
    "category": "Supplemental (wraparound) payment",
    "codes": "",
    "question": "How do Missouri FQHCs get made whole on managed care claims?",
    "answer": "FQHCs that contract with an MO HealthNet MCO can get supplemental payments of up to 92% of managed care charges. These cover the gap between what MHD would have paid on those charges and what the MCOs paid in the period. Request them on MHD forms on a schedule agreed with MHD, at least every 4 months. They count as interim payments, and managed care charges are part of cost apportionment and the final settlement.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "13 CSR 70-26.010 MO HealthNet Program Benefits for Federally-Qualified Health Center Services (Missouri Code of State Regulations, eff. 5/30/2019)",
    "source_url": "https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-26.pdf",
    "source_section": "13 CSR 70-26.010(2)(C), (4)(B) (p.4)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-162",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet Managed Care (Healthy Blue, Home State Health, UnitedHealthcare; Show Me Healthy Kids)",
    "payer_type": "Managed Medicaid",
    "category": "MCO timely filing (Healthy Blue)",
    "codes": "",
    "question": "What is Healthy Blue Missouri's timely filing limit?",
    "answer": "Submit within 180 calendar days of the date of service on a CMS-1500 or UB-04 (CMS-1450), including when there's other insurance. For coordination of benefits, the limit is 365 days from the date of service, or 90 days from the primary payer's EOB if that's later. Payment disputes are due within 365 days. Check each plan's contract for its own limits.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Healthy Blue (Missouri) MO HealthNet Managed Care Provider Manual, eff. 11/1/2026",
    "source_url": "https://provider.healthybluemo.com/docs/gpp/MO_CAID_HealthNetManagedCareProviderManual.pdf",
    "source_section": "Claims Submission and Timely Filing Requirements (pp.175-176); Quick reference - payment disputes (p.12)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-163",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Missouri",
    "payer": "MO HealthNet Managed Care (Healthy Blue, Home State Health, UnitedHealthcare; Show Me Healthy Kids)",
    "payer_type": "Managed Medicaid",
    "category": "FQHC access in managed care",
    "codes": "",
    "question": "Can Missouri managed care members use an FQHC?",
    "answer": "Healthy Blue covers FQHC services, including behavioral health, if the member lives in the clinic's service area and either picks the FQHC as their PCP, needs emergency care, or asks Member Services for care at the clinic. FQHCs can also be PCPs in plan networks.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "Healthy Blue (Missouri) MO HealthNet Managed Care Provider Manual, eff. 11/1/2026",
    "source_url": "https://provider.healthybluemo.com/docs/gpp/MO_CAID_HealthNetManagedCareProviderManual.pdf",
    "source_section": "Covered services table - FQHCs/RHCs (p.43)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MO-164",
    "region": "Region 7",
    "state_abbr": "MO"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "",
    "question": "How do I get reimbursed for office visits for Nebraska Medicaid?",
    "answer": "Nebraska pays FQHCs an all-inclusive PPS encounter rate. An encounter is a face-to-face visit with a physician, PA, NP, nurse midwife, specialized NP, visiting nurse, clinical psychologist or clinical social worker during which an FQHC service is given. Bill under the FQHC provider number on the institutional claim (837I / CMS-1450 UB-04), with the appropriate HCPCS/CPT and revenue codes. Most Nebraska Medicaid members are in Heritage Health managed care, and their claims go to the plan.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Nebraska DHHS 471-000-76, Nebraska Medicaid Billing Instructions for Federally Qualified Health Center Services (rev. May 15, 2024)",
    "source_url": "https://dhhs.ne.gov/Documents/471-000-76.pdf",
    "source_section": "Claim Formats (p.1-2); 471 NAC 29-003.01 and 29-006",
    "last_verified": "2026-10-30",
    "confidence": "High - claim format read directly in 471-000-76; encounter definition from the official 471 NAC 29 (dated 2010; Medium).",
    "id": "NE-165",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "",
    "question": "Can a Nebraska FQHC bill more than one encounter on the same day?",
    "answer": "Usually not. Encounters with more than one health professional, and multiple encounters with the same professional, on the same day at one location count as a single visit. The exception is when the patient, after the first encounter, has an illness or injury that needs more diagnosis or treatment. One claim may not cover more than one calendar day.",
    "claim_format": "UB-04 / 837I",
    "source_title": "471 NAC Chapter 29, Federally-Qualified Health Centers (official chapter PDF dated 03-10-2010, Nebraska Rules and Regulations site)",
    "source_url": "https://rules.nebraska.gov/api/fileStorage/GetAsByteArray/chapter-pdfs/471%20NAC%2029%20%2803-10-2010%29.pdf",
    "source_section": "29-003.01 Definitions; 471-000-76 FL 6",
    "last_verified": "2026-10-30",
    "confidence": "Medium - re-read 2026-10-30 in the official 471 NAC 29 PDF; the chapter is dated 03-10-2010 (it still names the former Nebraska Health Connection), so confirm current DHHS practice.",
    "id": "NE-166",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "CMS-1450 / 837I; CMS-1500 / 837P; ADA / 837D",
    "question": "Which claim form does a Nebraska FQHC use for Medicaid?",
    "answer": "FQHC services go under the FQHC provider number on the 837I or CMS-1450 (UB-04). HEALTH CHECK (EPSDT) exams go on the 837P or CMS-1500. Dental goes on the 837D or the ADA claim form. Lab, radiology and other non-FQHC services are billed on the CMS-1500 or 837P under the non-FQHC provider number. Claims for managed care members go to the Heritage Health plan, following the plan's instructions.",
    "claim_format": "UB-04 / 837I (EPSDT and non-FQHC on CMS-1500 / 837P; dental on ADA / 837D)",
    "source_title": "Nebraska DHHS 471-000-76, Nebraska Medicaid Billing Instructions for Federally Qualified Health Center Services (rev. May 15, 2024)",
    "source_url": "https://dhhs.ne.gov/Documents/471-000-76.pdf",
    "source_section": "Introduction; Claim Formats; Paper Claims (p.1-2); 471 NAC 29-006",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-167",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form details",
    "codes": "",
    "question": "What UB-04 fields does Nebraska Medicaid require on FQHC claims?",
    "answer": "The statement-covers period can't be more than one calendar day. HCPCS codes are required on all outpatient lines except pharmacy, supplies and dialysis, with up to four modifiers. Units must be whole numbers, and charges must be greater than zero. Put the billing NPI in FL 56, use patient relationship code 18 in FL 59, and enter the 11-digit Medicaid ID in FL 60. Don't enter Medicare payments, earlier Medicaid payments or write-offs as prior payments.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Nebraska DHHS 471-000-76, Nebraska Medicaid Billing Instructions for Federally Qualified Health Center Services (rev. May 15, 2024)",
    "source_url": "https://dhhs.ne.gov/Documents/471-000-76.pdf",
    "source_section": "CMS-1450 Form Completion: FL 6, 44, 46, 47, 54, 56, 59, 60 (p.3-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-168",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate / annual update",
    "codes": "",
    "question": "How is the Nebraska FQHC PPS rate set and updated?",
    "answer": "The PPS base rate came from reasonable costs in the FQHC's FY1999 and FY2000 cost reports, divided by total adjusted visits. It's updated each year by the Medicare Economic Index (MEI). A new FQHC gets an interim rate equal to the statewide average PPS rate. That interim rate is settled later from its first cost report, which also sets its own base rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "471 NAC Chapter 29, Federally-Qualified Health Centers (official chapter PDF dated 03-10-2010, Nebraska Rules and Regulations site)",
    "source_url": "https://rules.nebraska.gov/api/fileStorage/GetAsByteArray/chapter-pdfs/471%20NAC%2029%20%2803-10-2010%29.pdf",
    "source_section": "29-004.01 and 29-004.02",
    "last_verified": "2026-10-30",
    "confidence": "Medium - re-read 2026-10-30 in the official 471 NAC 29 PDF; the chapter is dated 03-10-2010 (it still names the former Nebraska Health Connection), so confirm current DHHS practice.",
    "id": "NE-169",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Rate schedule / APM",
    "codes": "",
    "question": "Where can I find Nebraska's published FQHC encounter rates?",
    "answer": "Nebraska DHHS posts a CY2026 FQHC rate schedule, effective January 1, 2026. It lists each FQHC site's rate in two sections: in-state FQHCs paid under an Alternative Payment Methodology (APM) and in-state FQHCs paid under PPS, with a statewide average for each. This site doesn't copy facility rates. Check the schedule for your site.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Nebraska DHHS - Federal Qualified Health Centers (FQHC) rate schedule, CY2026 (effective January 1, 2026)",
    "source_url": "https://dhhs.ne.gov/Medicaid%20Practitioner%20Fee%20Schedules/CY26%20FQHC%20Rates.pdf",
    "source_section": "CY2026 schedule: APM rates and PPS rates sections",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-170",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth / virtual",
    "codes": "",
    "question": "Does Nebraska Medicaid pay the FQHC encounter rate for telehealth?",
    "answer": "Under 471 NAC 29, telehealth is paid at the Medicaid rate for the comparable in-person service. FQHC core services by telehealth aren't covered under the encounter rate. Transmission costs for non-core services are paid at the lower of the charge or the maximum allowable, for real-time two-way audio-video only. This rule is old, and Nebraska's telehealth policy may have changed, so check current DHHS guidance.",
    "claim_format": "UB-04 / 837I",
    "source_title": "471 NAC Chapter 29, Federally-Qualified Health Centers (official chapter PDF dated 03-10-2010, Nebraska Rules and Regulations site)",
    "source_url": "https://rules.nebraska.gov/api/fileStorage/GetAsByteArray/chapter-pdfs/471%20NAC%2029%20%2803-10-2010%29.pdf",
    "source_section": "29-004.05 and 29-004.05A",
    "last_verified": "2026-10-30",
    "confidence": "Low - official 471 NAC 29 text, but dated 03-10-2010; Nebraska telehealth policy may have changed since.",
    "id": "NE-171",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Lab, radiology and non-FQHC services",
    "codes": "",
    "question": "How are non-FQHC services paid for Nebraska FQHCs?",
    "answer": "Non-FQHC services are paid from the Nebraska Medicaid Practitioners Fee Schedule. Lab, radiology and other non-FQHC services are billed on the CMS-1500 or 837P under the non-FQHC provider number.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "471 NAC Chapter 29, Federally-Qualified Health Centers (official chapter PDF dated 03-10-2010, Nebraska Rules and Regulations site)",
    "source_url": "https://rules.nebraska.gov/api/fileStorage/GetAsByteArray/chapter-pdfs/471%20NAC%2029%20%2803-10-2010%29.pdf",
    "source_section": "29-004.04 and 29-006",
    "last_verified": "2026-10-30",
    "confidence": "Medium - re-read 2026-10-30 in the official 471 NAC 29 PDF; the chapter is dated 03-10-2010 (it still names the former Nebraska Health Connection), so confirm current DHHS practice.",
    "id": "NE-172",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "CMS-222",
    "question": "Do Nebraska FQHCs file a Medicaid cost report?",
    "answer": "Yes. FQHCs in Nebraska Medicaid must send DHHS an annual cost report. The rule points to the Medicare FQHC cost report form (CMS-222-92 at the time it was written). FQHCs must also give DHHS cost reports and other documentation when asked.",
    "claim_format": "UB-04 / 837I",
    "source_title": "471 NAC Chapter 29, Federally-Qualified Health Centers (official chapter PDF dated 03-10-2010, Nebraska Rules and Regulations site)",
    "source_url": "https://rules.nebraska.gov/api/fileStorage/GetAsByteArray/chapter-pdfs/471%20NAC%2029%20%2803-10-2010%29.pdf",
    "source_section": "29-005",
    "last_verified": "2026-10-30",
    "confidence": "Medium - re-read 2026-10-30 in the official 471 NAC 29 PDF; the chapter is dated 03-10-2010 (it still names the former Nebraska Health Connection), so confirm current DHHS practice.",
    "id": "NE-173",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Nebraska Medicaid (DHHS MLTC fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossovers / TPL",
    "codes": "",
    "question": "How does a Nebraska FQHC bill Medicaid as secondary payer?",
    "answer": "Bill the other payer first (Medicare or private insurance). After that payer decides, send the claim to Nebraska Medicaid with a copy of the remittance advice, denial or other documentation. Medicare crossover instructions are in 471-000-70. In FL 54, list payments from other sources (insurance, liability, excess income) but not Medicare payments.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Nebraska DHHS 471-000-76, Nebraska Medicaid Billing Instructions for Federally Qualified Health Center Services (rev. May 15, 2024)",
    "source_url": "https://dhhs.ne.gov/Documents/471-000-76.pdf",
    "source_section": "Third Party Resources (p.1); FL 54 (p.6)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-174",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Heritage Health (Molina Healthcare of NE, Nebraska Total Care, UnitedHealthcare Community Plan of NE)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / MCO overview",
    "codes": "",
    "question": "Does Nebraska use managed care MCOs for Medicaid?",
    "answer": "Yes. Heritage Health is Nebraska's Medicaid managed care program. One plan covers physical health, behavioral health, dental and pharmacy. The three plans are Molina Healthcare of Nebraska, Nebraska Total Care and UnitedHealthcare Community Plan of Nebraska. Not covered by the plans (still Medicaid): ICF/DD services, custodial nursing facility care, school-based services, HCBS waiver services and personal assistance services. Members choose a Dental Home through their plan.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Heritage Health (Nebraska Medicaid Managed Care) Member Guidebook (revised 5/2025)",
    "source_url": "https://www.neheritagehealth.com/Files/Heritage_Health_Member_Guidebook_2026.pdf?ver=0.36",
    "source_section": "Welcome to Heritage Health (p.5); Health Plan Benefits; Services Not Covered by Your Health Plan (p.6-7); Choose a Dental Home",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-175",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Heritage Health (Molina Healthcare of NE, Nebraska Total Care, UnitedHealthcare Community Plan of NE)",
    "payer_type": "Managed Medicaid",
    "category": "Wraparound / supplemental payments",
    "codes": "",
    "question": "Does Nebraska pay a wraparound to FQHCs for managed care visits?",
    "answer": "Yes. FQHCs under contract with a Medicaid managed care entity get quarterly state supplemental payments. These estimate the gap between what the plan paid and what PPS would have paid. At the end of each FQHC fiscal year, DHHS compares total plan plus supplemental payments with what PPS would have paid for the actual managed care visits. DHHS pays any shortfall, and the FQHC refunds any overpayment.",
    "claim_format": "UB-04 / 837I",
    "source_title": "471 NAC Chapter 29, Federally-Qualified Health Centers (official chapter PDF dated 03-10-2010, Nebraska Rules and Regulations site)",
    "source_url": "https://rules.nebraska.gov/api/fileStorage/GetAsByteArray/chapter-pdfs/471%20NAC%2029%20%2803-10-2010%29.pdf",
    "source_section": "29-004.03 and 29-004.03A",
    "last_verified": "2026-10-30",
    "confidence": "Medium - re-read 2026-10-30 in the official 471 NAC 29 PDF; the chapter is dated 03-10-2010 (it still names the former Nebraska Health Connection), so confirm current DHHS practice.",
    "id": "NE-176",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Heritage Health (Molina Healthcare of NE, Nebraska Total Care, UnitedHealthcare Community Plan of NE)",
    "payer_type": "Managed Medicaid",
    "category": "Plan reimbursement",
    "codes": "",
    "question": "How does Nebraska Total Care pay FQHCs?",
    "answer": "Nebraska Total Care pays FQHCs and RHCs under 471 NAC Chapters 29 and 34. It won't enter into an alternative payment arrangement started by an FQHC without prior MLTC approval. Out-of-network FQHC services need prior approval unless they treat an emergency or no plan offers FQHC services within MLTC travel standards.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Nebraska Total Care - 2026 Provider Billing Guide (PROV16-NE-00025, 01/01/2026)",
    "source_url": "https://www.nebraskatotalcare.com/content/dam/centene/Nebraska/PDFs/ProviderRelations/NTC_Provider_Billing_Guide_12152025_01132026_508.pdf",
    "source_section": "Reimbursement to FQHCs & RHCs (p.27)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-177",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Nebraska",
    "payer": "Heritage Health (Molina Healthcare of NE, Nebraska Total Care, UnitedHealthcare Community Plan of NE)",
    "payer_type": "Managed Medicaid",
    "category": "Timely filing",
    "codes": "",
    "question": "What is the timely filing limit for Nebraska Total Care?",
    "answer": "Claims and encounters are due within 180 calendar days of the date of service. With retroactive eligibility, the limit can be extended up to 180 calendar days. When Nebraska Total Care is secondary, the limit is 365 days from the date of service. Reconsiderations and corrected claims are due within 90 days of the payment or denial notice, and appeals within 60 days.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Nebraska Total Care - 2026 Provider Billing Guide (PROV16-NE-00025, 01/01/2026)",
    "source_url": "https://www.nebraskatotalcare.com/content/dam/centene/Nebraska/PDFs/ProviderRelations/NTC_Provider_Billing_Guide_12152025_01132026_508.pdf",
    "source_section": "Timely Filing (p.24)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "NE-178",
    "region": "Region 7",
    "state_abbr": "NE"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "",
    "question": "How do I get reimbursed for office visits for Health First Colorado?",
    "answer": "Freestanding FQHC services are paid at an encounter rate, and all routine services are included in it. Bill the UB-04 / 837I with type of bill 77X. At least one line must carry revenue code 0529 (physical health). The 0529 line can be anywhere on the claim and can carry any procedure code. Put the revenue code that fits on every other line, and report every CPT/HCPCS code for the visit. Colorado pays separate per-visit rates for physical health, dental and specialty behavioral health services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "FQHCs and RHCs Benefits; UB-04 Paper Claim Reference Table FL 4, 42, 44",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-179",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Billable visit definition",
    "codes": "",
    "question": "What counts as a billable FQHC visit in Colorado?",
    "answer": "A visit is a one-on-one encounter between the patient and an eligible practitioner providing FQHC services. It can be face-to-face, interactive audio, interactive video or interactive data communication. Eligible practitioners include physicians, dentists, dental hygienists, dental therapists, PAs, NPs, nurse-midwives, visiting nurses, clinical psychologists, podiatrists, LCSWs, LMFTs, LPCs and LACs. Certain supervised candidates for mental health licensure also count. Group sessions don't create a billable encounter. Peer support, pharmacist services and eConsults aren't billable visits, but their costs go on the cost report.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.1.B-C (p.1-2); billing manual sections on Peer Support, Pharmacist Services and eConsults",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-180",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "",
    "question": "Can a Colorado FQHC get paid for more than one encounter in a day?",
    "answer": "Yes, up to three per day at the same location: one physical health, one dental and one specialty behavioral health encounter. Dental encounters count only when the dental ASO (DentaQuest) covers and pays them. Specialty behavioral health encounters count only when the RAE covers them, or under the short-term BH policy. Several physical health encounters on one day count as a single visit unless the patient has a new illness or injury after the first one. Bill a qualifying second physical health visit on its own UB-04 with a different diagnosis. Only one behavioral health encounter is paid per patient per day.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.A and 8.700.6.C (p.5-6); manual: Same-Day Physical Health Visits",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-181",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Rate setting / APM",
    "codes": "",
    "question": "How are Colorado FQHC encounter rates set?",
    "answer": "Colorado sets rates under an alternative payment methodology (APM 1), with rates based on 100% of reasonable cost. Each service-specific rate is the lower of the annual rate (current year's audited, inflated cost per visit) and the base rate (the weighted average over three years, rebased every year). Since July 1, 2020, part of the physical health APM rate has been at risk based on the FQHC's quality modifier. Each year HCPF reconciles to make sure every FQHC got at least its BIPA PPS per-visit rate, and it makes a one-time payment to cover any shortfall.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.D and 8.700.6.D.2 (p.6-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-182",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "APM 2 / PMPM",
    "codes": "",
    "question": "What is Colorado's APM 2 for FQHCs?",
    "answer": "APM 2 is an optional per member per month (PMPM) payment, and FQHCs can opt in each year. It converts the FQHC's physical health cost-per-visit rate into a PMPM using historical use and attributed members. Several groups are still paid at encounter rates: patients who aren't attributed to the FQHC or are attributed only by geography, dual eligibles (who are excluded), and all dental and specialty BH services. A separate Chronic Condition Incentive Payment can be elected each quarter. HCPF reconciles each year so PMPM payments are no less than PPS.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.D.7-10 (p.15-16); manual: Billing Information (APM 2 Billing Guidance)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-183",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "",
    "question": "When is the Colorado Medicaid FQHC cost report due?",
    "answer": "Within 90 days after the FQHC's fiscal year ends, on the Department's Medicaid FQHC Cost Report form. An extension of up to 75 days is possible. A freestanding FQHC that hasn't filed within 180 days has its payments suspended. Supporting documents are due within 10 business days of a request. New rates take effect 120 days after fiscal year end.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.D.4 (p.8)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-184",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How do I request a change in scope of service in Colorado?",
    "answer": "When a documented change in scope of service changes costs, the FQHC must apply to HCPF to adjust its PPS rate. HCPF makes the adjustment under SSA 1902(bb). The change must involve a covered FQHC benefit under SSA 1905(a)(2)(C) that the FQHC provides, and it must meet the other conditions listed in 8.700.6.D.5.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.D.5 (p.9 ff.)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-185",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth / virtual",
    "codes": "GT; FQ; FR",
    "question": "How do I bill telehealth for Health First Colorado at an FQHC?",
    "answer": "In-person and telemedicine visits are both billable encounters. Telemedicine is limited to the codes in the Telemedicine Billing Manual and needs modifier GT. Add FQ for audio-only, or FR when the supervising practitioner was present by two-way audio-video. An FQHC acting as an originating site bills the originating-site code on a CMS-1500. Text, email and fax don't count as visits.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "Telemedicine; 8.700.1.C",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-186",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health / RAE billing",
    "codes": "",
    "question": "Do I bill behavioral health to Health First Colorado or to the RAE?",
    "answer": "Since July 1, 2025, short-term psychotherapy codes (formerly the STBH benefit) are billed to the member's RAE with revenue code 900. Bill integrated care codes (HBAI and CoCM) straight to HCPF with revenue code 900, at the encounter rate; no BH diagnosis is needed. FFS behavioral health E/M also goes to HCPF on revenue code 900. One BH encounter is allowed per day, and you can't bill RAE psychotherapy and integrated care on the same day. If integrated care and a medical visit happen on the same day, submit two claims (rev 900 and rev 529).",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "Short-Term Behavioral Health Services; Integrated Care Services; Behavioral Health E/M Codes",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-187",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "ADA / 837D",
    "question": "How do Colorado FQHCs bill dental for Medicaid?",
    "answer": "Send FQHC dental claims to DentaQuest, the dental ASO, on the current ADA claim form or as an 837D through the DentaQuest portal. Include CDT codes. Dental is paid at its own encounter rate. Dentures are paid separately, at the lower of charges or the fee schedule.",
    "claim_format": "ADA / 837D",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "Dental Services; 8.700.6.B.3",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-188",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services paid outside the encounter",
    "codes": "",
    "question": "What is paid outside the Colorado FQHC encounter rate?",
    "answer": "Under 8.700.6.B, these are paid at the lower of charges or the fee schedule: LARC devices (on top of the encounter for insertion, billed on the CMS-1500), inpatient hospital services, dentures, outpatient hospital dental, and antagonist injections for substance use disorder. Also outside the rate: Prenatal Plus and Nurse Home Visitor Program services (CMS-1500, supplemental fee schedule) and FQHC pharmacy claims (separate billing number). Labor-and-delivery-only services go on a CMS-1500. Prenatal and postpartum visits are not bundled and go on the UB-04.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.B (p.5-6); manual: FQHC Services, LARC, Obstetrics Billing",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-189",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Physician-administered drugs / 340B",
    "codes": "UD modifier",
    "question": "How do Colorado FQHCs report 340B drugs on Medicaid claims?",
    "answer": "Report all non-carved-out physician-administered drugs, with a valid NDC (N4 qualifier, 11-digit NDC, unit qualifier and quantity in FL 43). Add modifier UD to drugs bought through 340B. Missing NDCs or NCCI conflicts can cause $0 payment.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "National Drug Code; Zero Pay Claims; FL 43",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-190",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing",
    "codes": "",
    "question": "What is the Health First Colorado timely filing limit?",
    "answer": "365 days from the date of service (effective June 1, 2018). Claims filed later need a timely filing waiver with supporting documentation. After the first period runs out, re-bills and adjustments must follow the 60-day rule and cite the previous ICN. Claims for Medicare-denied or exhausted benefits are due within 365 days of the date of service or 120 days of the Medicare denial, whichever is later.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - General Provider Information Manual",
    "source_url": "https://hcpf.colorado.gov/gen-info-manual",
    "source_section": "Timely Filing - Original Timely Filing; Re-Bills and Adjustments and the 60-Day Rule; Claims for Medicare-Exhausted Benefits",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-191",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossovers / TPL",
    "codes": "",
    "question": "How does a Colorado FQHC bill when the patient has Medicare or other insurance?",
    "answer": "Meet Medicare, TPL and coordination of benefits rules before you bill Health First Colorado. If Health First Colorado covers a service that Medicare doesn't, or Medicare won't pay because of the provider type, bill Health First Colorado on the encounter revenue code line, limited to its allowed amount. On crossovers, FL 55 is the Medicare coinsurance plus deductible, minus third-party and member payments.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "Medicare and Third-Party Liability (TPL) Billing; FL 54-55",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-192",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Health First Colorado (HCPF fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Sites, mobile units and enrollment",
    "codes": "",
    "question": "Does each Colorado FQHC site need its own Medicaid enrollment?",
    "answer": "Yes. Each FQHC location enrolls separately and gets its own provider ID. Hospital-based FQHCs can use one ID for every site on the main campus. Mobile units and temporary sites, including vaccination sites, don't enroll separately and bill from the location where they're based. Under C.R.S. 25.5-4-420, a site that becomes permanent needs its own NPI and enrollment.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Health First Colorado (HCPF) - Federally Qualified Health Center and Rural Health Clinic Billing Manual (revisions log through 07/15/2026)",
    "source_url": "https://hcpf.colorado.gov/fqhc-rhc",
    "source_section": "Temporary Service Sites and Mobile Units",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-193",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Accountable Care Collaborative - RAEs and MCOs (RMHP / RMHP Prime, NHP, CCHA, Colorado Access, Elevate Medicaid Choice)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / MCO overview",
    "codes": "",
    "question": "Does Colorado use managed care MCOs for Medicaid?",
    "answer": "Mostly not for physical health. The Accountable Care Collaborative (ACC) is the main delivery system. Four Regional Accountable Entities (RAEs) run the capitated behavioral health benefit and coordinate care, and most physical health is paid by HCPF fee-for-service. Two physical health MCOs cover certain areas. Phase III RAEs from July 1, 2025: Region 1 Rocky Mountain Health Plans (with RMHP Prime), Region 2 Northeast Health Partners, Region 3 Colorado Community Health Alliance, Region 4 Colorado Access. The MCO is Elevate (Denver Health) Medicaid Choice. For MCO members (for example vaccines through an affiliated pharmacy), the billing manual says to send the claim to the MCO.",
    "claim_format": "UB-04 / 837I",
    "source_title": "HCPF - Accountable Care Collaborative Phase III (RAEs and MCOs from July 1, 2025)",
    "source_url": "https://hcpf.colorado.gov/accphase3",
    "source_section": "About ACC Phase III; Meet the ACC Phase III RAEs and MCOs",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "CO-194",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Colorado",
    "payer": "Accountable Care Collaborative - RAEs and MCOs (RMHP / RMHP Prime, NHP, CCHA, Colorado Access, Elevate Medicaid Choice)",
    "payer_type": "Managed Medicaid",
    "category": "Behavioral health capitation and FQHC rates",
    "codes": "",
    "question": "Is RAE behavioral health part of the Colorado FQHC encounter rate?",
    "answer": "Yes. Specialty behavioral health is its own FQHC encounter rate. It covers BH services that the RAE covers and pays, or that were paid under the short-term BH policy. HCPF reconciles each year to make sure FQHCs received at least their PPS per-visit rate. RAE contracting, claim rules and timely filing come from each RAE; this site hasn't summarized those manuals yet.",
    "claim_format": "UB-04 / 837I",
    "source_title": "10 CCR 2505-10 Section 8.700, Federally Qualified Health Centers (Code of Colorado Regulations, Medical Services Board)",
    "source_url": "https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=2924&seriesNum=10+CCR+2505-10+8.700",
    "source_section": "8.700.6.A and 8.700.6.D (p.5-6)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the regulation says how RAE-paid visits fit into FQHC rates; RAE-specific billing rules weren't reviewed.",
    "id": "CO-195",
    "region": "Region 8",
    "state_abbr": "CO"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "Rev 0521; Rev 0900; Rev 0512",
    "question": "How do I get reimbursed for office visits for Montana Medicaid?",
    "answer": "Montana pays FQHCs a facility-specific PPS rate per visit, meant to reflect 100% of reasonable costs. Bill the visit on the UB-04 (or 837I) with a revenue code such as 0521 (clinic visit), 0900 (behavioral health) or 0512 (dental) and an allowable procedure code. A qualifying visit is a one-to-one encounter between the member and a health professional. Codes for clinical staff time, or other services that don't meet the visit definition, can't be billed at the PPS rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "FQHC and RHC Reimbursement Methodology (p.8); Claim Forms and Revenue Codes (p.15)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-196",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "UB-04; CMS-1500",
    "question": "Which claim form does a Montana FQHC use, and when is the CMS-1500 allowed?",
    "answer": "Bill FQHC services electronically or on a paper UB-04. Services performed in a hospital setting go on the CMS-1500, with the FQHC NPI as the billing provider and the individual practitioner as the rendering provider. The few services paid outside PPS also go on the CMS-1500. Anything billed on a CMS-1500 is paid a fee-for-service rate, not the PPS rate. Paper claims go to Claims, P.O. Box 8000, Helena, MT 59604.",
    "claim_format": "UB-04 / 837I (CMS-1500 for hospital-setting and non-PPS services)",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Claim Forms (p.15); see also MTQ notice",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-197",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Revenue codes",
    "codes": "0512, 0521, 0522, 0524, 0525, 0527, 0528, 0636, 0770, 0771, 0780, 0900, 0942, 0944, 0969",
    "question": "Which revenue codes can a Montana FQHC bill?",
    "answer": "The manual lists 0512 (dental visit), 0521 (clinic visit), 0522 (home visit), 0524 and 0525 (visits to members in a skilled nursing or other facility), 0527 (visiting nurse in a home health shortage area), 0528 (other non-clinic site), 0636 (HMK vaccines and LARCs), 0770 (clinical pharmacist practitioner), 0771 (vaccine administration), 0780 (telehealth originating site), 0900 (behavioral health), 0942 (DSMES), 0944 (SUD) and 0969 (Promising Pregnancy Care group education). Montana FQHCs have no fee schedule of their own; use the OPPS fee schedule to check which codes are allowable.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Revenue Codes (p.15-16)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-198",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "",
    "question": "Can a Montana FQHC be paid for more than one visit on the same day?",
    "answer": "Generally one encounter per member per day. Exceptions are when the member must be seen by health professionals of different specialties, or seen more than once for unrelated diagnoses. Providers of the same specialty in the same visit count as one encounter. Lines with the same revenue code on the same date bundle into one PPS payment. Lines with different revenue codes for distinct qualifying encounters with core providers of different specialties are each paid at the PPS rate. Span billing is not allowed: one date of service per claim.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Number of Lines on Claim; Multiple Services on Same Date (p.16); Span Billing (p.17)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-199",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Qualifying visit / practitioners",
    "codes": "",
    "question": "Which practitioners create a billable FQHC visit in Montana?",
    "answer": "Core services that can be billed as a visit: physician; NP, nurse specialist, certified nurse midwife or PA; clinical psychologist, clinical social worker, LPC, licensed addiction counselor, LMFT, or in-training mental health professional; dental services; visiting nurse services (42 CFR 405.2416); and clinical pharmacist practitioner services. Services incidental to these providers (lab techs, LPNs, radiology and similar) are included in the rate and can't be billed as a stand-alone visit, even on a separate day. Pharmacist-only visits, outreach and transportation are also incidental. Each clinic and each rendering provider must keep a current Montana Medicaid enrollment.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Clinic Covered Core Services (p.18); FQHC and RHC Limitations (p.17)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-200",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services outside PPS",
    "codes": "H0038; Q3014; 0403T; Rev 0636; Rev 0969",
    "question": "Which Montana FQHC services are paid outside the PPS rate?",
    "answer": "Only these: certified behavioral health peer support (CMS-1500, H0038, paid at the lower of billed charges or the OPPS rate); LARC devices (UB-04, revenue code 0636, lower of charges or average acquisition cost; NDC required unless the provider is a registered 340B provider); Promising Pregnancy Care group education (revenue code 0969 at the OPPS rate, with the OB visit itself at PPS; needs DPHHS approval); the telehealth originating-site fee (revenue code 0780 with Q3014, not billable when the originating site is the member's home); HMK vaccines; and services in a hospital setting. The manual also lists Diabetes Prevention Program group sessions (0403T on a CMS-1500).",
    "claim_format": "Varies by service (see answer)",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Services Reimbursed Outside the PPS Rate (p.22-23); MTQ notice",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-201",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Vaccines",
    "codes": "Rev 0636; Rev 0771; 90471-90474; 90480",
    "question": "Does Montana Medicaid pay an FQHC separately for vaccines?",
    "answer": "No for Medicaid members: vaccines and their administration are incident to the core-provider visit and are not separately billable, and nurse-only vaccine visits are not paid. The exception is Healthy Montana Kids (HMK) children, who aren't eligible for VFC: bill the vaccine under revenue code 0636 with the vaccine code. An HMK nurse-only administration visit uses revenue code 0771 (admin codes 90471-90474, 90480). If the administration was part of a core-provider visit, it bundles into that visit.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Vaccine Reimbursement (p.21)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-202",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health",
    "codes": "90791, 90832, 90834, 90837, 90853; Rev 0944; Rev 0900",
    "question": "How does a Montana FQHC bill behavioral health and SUD services?",
    "answer": "Behavioral health visits with core mental health providers bill under revenue code 0900 at the PPS rate. Substance use disorder services need an approved change-in-scope request first. Then bill revenue code 0944 with 90791, 90832, 90834, 90837 or 90853, paid at the PPS rate; the rendering provider must be acting within their scope of licensure.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Revenue Codes (p.15-16); Substance Use Disorder (SUD) Services (p.20)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-203",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "Rev 0512",
    "question": "How are dental and hygienist services billed by a Montana FQHC?",
    "answer": "Dental is a core service billed under revenue code 0512. A billable dental encounter includes services by dental hygienists supervised by a dentist, and by Limited Access Permit (LAP) hygienists under public health supervision. LAP hygienists must enroll as rendering-only providers. Fluoride-varnish-only encounters are included in the PPS rate and are not a stand-alone visit. Dental program limits (for example, AbCd certification) still apply.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Dental Hygienist and LAP Services (p.19); FQHC and RHC Limitations (p.17)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-204",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Pharmacist / DSMES",
    "codes": "99605, 99606, G0108; Rev 0770; Rev 0942",
    "question": "Can a Montana FQHC bill clinical pharmacist practitioner or diabetes education visits?",
    "answer": "Yes. Clinical pharmacist practitioner (CPP) services need an approved change in scope. They are billed with revenue code 0770 and 99605 or 99606 for each qualifying face-to-face visit, and paid at the PPS rate. DSMES by a core provider that meets the visit definition is billed as G0108 with revenue code 0942 and paid at the PPS rate.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Clinical Pharmacist Practitioner (CPP) Services (p.19-20); DSMES (p.20)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-205",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "PPS rate setting",
    "codes": "",
    "question": "How is a Montana FQHC's PPS rate set and updated?",
    "answer": "A new FQHC gets an interim rate for its first two complete fiscal years: 100% of the average PPS rate of similar FQHCs in the same or adjacent area, or projected allowable costs divided by projected visits if there are none. After two complete fiscal years, a baseline rate is set from the first two as-filed Medicare cost reports, due six months after the second fiscal year ends. It is retroactive to enrollment, with a mass claims adjustment. The baseline rate is adjusted by the MEI on January 1 each year.",
    "claim_format": "n/a",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "How is the PPS rate calculated?; Interim and Baseline PPS Rate (ARM 37.86.4413) (p.8-9)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-206",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How does a Montana FQHC request a change in scope of service?",
    "answer": "Apply in writing to the DPHHS FQHC/RHC Program Officer (email, or P.O. Box 202951, Helena, MT 59620), even if the rate won't go up. A prospective request is due 120 days before the change and needs a narrative, the date, the affected cost centers, the prior-year cost report and a projected cost report. DPHHS sets a temporary rate within 90 days. A retrospective request is allowed once per calendar year. The incremental change is the cost per visit after the change minus the cost per visit before it. A change in ownership, new sites offering the same services, or a change in visit volume does not qualify.",
    "claim_format": "n/a",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Change in Scope of Service (p.10-15)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-207",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossover / duals",
    "codes": "",
    "question": "How does Montana Medicaid pay FQHC Medicare crossover claims?",
    "answer": "FQHC claims cross over automatically from Medicare, so there is no need to send them on paper. Crossover FQHC claims are paid the Medicaid allowed amount minus the Medicare payment and any TPL. For QMB-only members the FQHC is paid the Medicare deductible and/or coinsurance. For QMB Plus members it is paid the difference between the Medicare payment and the PPS rate. No Medicare EOB is needed for LAC, CPP or peer support services, which Medicare doesn't cover.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Medicare Claims (p.24)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-208",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Care management / PCCM",
    "codes": "",
    "question": "Can a Montana FQHC bill care management, and is there managed Medicaid?",
    "answer": "Care management that isn't a face-to-face visit with a core provider is paid only through the state's primary care case management (PCCM) program. The 2026 manual calls it Primary Care Montana (PCMT); a 2024 notice named Passport to Health, Team Care and Patient Centered Medical Home, which pay a per-member-per-month amount. Neither FQHC document read describes risk-based Medicaid MCOs, so FQHC claims for Montana Medicaid go to the state's fiscal agent.",
    "claim_format": "n/a",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Clinic Covered Core Services (p.18); MTQ notice (p.1)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the PCCM program is stated in the sources; the absence of risk-based MCOs is inferred from these documents and not stated outright.",
    "id": "MT-209",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services away from center",
    "codes": "Rev 0522, 0524, 0525, 0528",
    "question": "Are Montana FQHC services covered outside the clinic?",
    "answer": "Yes. Allowable services are covered in outpatient settings including the clinic, another medical facility (including a dental office), or the member's residence, which can be a nursing facility or other institution used as home. Off-site services are covered if they are normally within the clinic's professional services. Services in a hospital setting are billed on the CMS-1500 at fee-for-service rates.",
    "claim_format": "UB-04 / 837I (CMS-1500 for hospital setting)",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Service Settings (p.17); Claim Forms (p.15)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "MT-210",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "Montana",
    "payer": "Montana Medicaid / Healthy Montana Kids (DPHHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "Q3014; Rev 0780",
    "question": "How does Montana handle telehealth for FQHCs?",
    "answer": "The FQHC manual covers only the originating-site fee: revenue code 0780 with Q3014, paid at the OPPS rate, and not billable when the member's home is the originating site. The claim must include the distant provider's diagnosis. For distant-site telehealth rules, the manual points to the Telemedicine chapter of the General Information for Providers Manual, which was not reviewed here.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Montana Healthcare Programs - FQHC and RHC Provider Manual (effective July 1, 2026)",
    "source_url": "https://medicaidprovider.mt.gov/docs/manuals/RHCFQHC/FederallyQualifiedHealthCenterandRuralHealthClinicProviderManualEffective070126.pdf",
    "source_section": "Telehealth Originating Site Fee (p.23)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - distant-site telehealth rules are in the General Information manual (not reviewed).",
    "id": "MT-211",
    "region": "Region 8",
    "state_abbr": "MT"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "Rev 0521",
    "question": "How do I get reimbursed for office visits for North Dakota Medicaid?",
    "answer": "ND Medicaid pays FQHCs an all-inclusive rate per encounter. An encounter can be medical, dental or behavioral health, and covers the services and supplies incident to it. An encounter is a face-to-face or synchronous telehealth visit in which a qualifying encounter service is given. Use the ND Medicaid Procedure Code Look-up Tool to check whether a code qualifies. FQHC services need no service authorization.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Covered Services and Limits (p.2); Service Authorization Requirements (p.5); Definitions (p.7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-212",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Qualifying visit / practitioners",
    "codes": "",
    "question": "Which practitioners generate an FQHC encounter in North Dakota?",
    "answer": "Medical encounters: physician, PA, NP, certified nurse-midwife, visiting nurse (homebound patient, written treatment plan, RN or LPN), licensed registered dietitian, podiatrist and optometrist. Behavioral health encounters: LCSW, LMSW (added January 2026), LPC, LPCC, LMFT, licensed psychologist, NP and licensed addiction counselor. Dental encounters: dentist. Hygienist services are billed under the supervising dentist. Servicing and billing NPIs must be enrolled with ND Medicaid on the date of service, and so must locum tenens providers.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Eligible Providers (p.1-2); Policy Updates (p.8)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-213",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Incident-to / lab and x-ray",
    "codes": "",
    "question": "Can a North Dakota FQHC bill lab, x-ray or nurse-only visits separately?",
    "answer": "No. A visit where only incident-to services are given (for example lab, x-rays or procedures done during the visit) doesn't qualify as an encounter. Those services are included in the encounter and can't be billed separately. Lab or x-ray with no face-to-face visit with a qualifying provider isn't paid separately from the encounter that ordered it.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Incident-to Services (p.2-3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-214",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "Modifier 59",
    "question": "Can a North Dakota FQHC bill more than one encounter on the same day?",
    "answer": "Seeing more than one professional, or getting several services from the same professional, on one day at one location is a single encounter. Payment is limited to one medical, one dental and one mental health visit per day, unless an illness or injury after the first encounter needs more diagnosis or treatment. If there are two encounters of the same type (two medical or two BH) on one day for separate diagnoses, put modifier 59 on the second. Don't use modifier 59 for encounters of different types. Bill each encounter type separately, with the correct revenue code and diagnoses on each claim.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Limits (p.3); Claim Requirements (p.6-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-215",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "UB-04; 837I; ADA/837D",
    "question": "Which claim form does a North Dakota FQHC use?",
    "answer": "Bill FQHC services on the UB-04 or 837I. Put each service on its own line with its revenue code, procedure code, date of service and usual charge. Since July 1, 2024, every service in the encounter must be on the claim; services that don't pay an encounter are reported for quality and informational purposes. For dates of service on or after January 1, 2026, dental encounter claims go on the ADA (837D) form, with the authorization number if one is needed.",
    "claim_format": "UB-04 / 837I (dental on ADA / 837D from 1/1/2026)",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Reimbursement; Claim Form; Claim Requirements (p.6-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-216",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Revenue codes",
    "codes": "0512, 0521, 0522, 0524, 0525, 0529, 0771, 0636",
    "question": "Which revenue codes does North Dakota Medicaid require for FQHC claims?",
    "answer": "0512 dental clinic; 0521 clinic visit; 0522 home visit; 0524 visit to a member in a covered Part A SNF stay; 0525 visit to a member in a SNF (not a covered Part A stay), NF, ICF/MR or other residential facility; 0529 behavioral health. Immunization administration must use 0771, not 0521, and the vaccine goes under 0636. Before 1/1/2026, all dental encounter services used 0512, and dental case management had to be billed with another qualifying dental service.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Claim Requirements (p.6-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-217",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Payment amount",
    "codes": "",
    "question": "Is a North Dakota FQHC paid the lesser of charges or the encounter rate?",
    "answer": "Yes. Submit claims at the provider's usual and customary charge. Payment is the lesser of that charge or the ND Medicaid calculated reimbursement. The policy doesn't publish rate amounts; ND HHS posts them on its Rates and Fee Schedules page.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Reimbursement (p.6)",
    "last_verified": "2026-10-30",
    "confidence": "High for the rule; rate amounts not reviewed.",
    "id": "ND-218",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Vaccines",
    "codes": "Rev 0771; Rev 0636",
    "question": "Does North Dakota Medicaid pay an FQHC separately for immunizations?",
    "answer": "When given with a medical encounter, the immunization and its administration are incident to the encounter and not paid on top of it. If immunization is the only service, bill the administration (revenue code 0771 with the CPT code), not an encounter, and include revenue code 0636 with the vaccine code. VFC-supplied vaccine isn't paid; only the administration is. Covered non-VFC vaccine is paid from the Medicaid fee schedule.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Immunizations (p.4)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-219",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "Rev 0512",
    "question": "When can a hygienist generate an encounter at a North Dakota FQHC?",
    "answer": "Hygienist services that can generate an encounter: full-mouth prophylaxis, full-mouth periodontal maintenance, scaling and root planing (at least one quadrant), dental screening or assessment when given with another qualifying service, and sealants given with another qualifying service in the school-based sealant program. These alone don't create an encounter: impressions, fluoride varnish, denture cleaning, suture removal, dental case management, and oral hygiene or nutrition or smoking-cessation education.",
    "claim_format": "ADA / 837D (DOS on or after 1/1/2026)",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Limits (p.3-4); Dental Claims (p.6-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-220",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "MNT / DSMT",
    "codes": "",
    "question": "Can medical nutrition therapy or diabetes self-management training be its own encounter in North Dakota?",
    "answer": "Only when it is the only medical service that day. MNT or DSMT on the same day as a medical encounter isn't a separate encounter. A registered nurse with diabetic educator certification can give DSMT under a licensed practitioner's supervision, and it is billed under the supervising practitioner's NPI.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Limits (p.3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-221",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services away from center",
    "codes": "",
    "question": "Where can North Dakota FQHC services be provided?",
    "answer": "Covered locations: the FQHC; the member's residence, including skilled nursing and assisted living facilities; and community sites such as homeless shelters, low-income housing, schools and the scene of an accident. FQHC services can't be given in an inpatient or outpatient hospital department (including a critical access hospital) or in a facility whose requirements preclude FQHC visits.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Service Location (p.3)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-222",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "",
    "question": "Do telehealth visits count as FQHC encounters in North Dakota?",
    "answer": "Yes, if synchronous. The policy defines an encounter as a face-to-face or synchronous telehealth visit in which a qualifying encounter service is given. The FQHC policy doesn't address audio-only or asynchronous services.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Definitions (p.7)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the policy covers only the definition; check ND Medicaid's telehealth policy for modifiers and POS.",
    "id": "ND-223",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "North Dakota Medicaid (HHS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing / records",
    "codes": "",
    "question": "What is North Dakota Medicaid's timely filing limit for FQHC claims?",
    "answer": "ND Medicaid must receive an original Medicaid-primary claim within 180 days of the date of service; the state can waive or extend this in some cases. Keep medical and financial records for at least 7 years after the claim was last paid or denied. ND Medicaid is generally the payer of last resort.",
    "claim_format": "UB-04 / 837I",
    "source_title": "North Dakota Medicaid Billing and Policy Manual - Federally Qualified Health Centers (FQHC), updated January 2026",
    "source_url": "https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/federally-qualified-health-centers-FQHC.pdf",
    "source_section": "Timely Filing; Third-Party Liability; Documentation Requirements (p.5)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-224",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "Medicaid Expansion - Blue Cross Blue Shield of North Dakota (BCBSND)",
    "payer_type": "Managed Medicaid",
    "category": "Managed care overview",
    "codes": "",
    "question": "Does North Dakota have managed Medicaid that affects FQHCs?",
    "answer": "Only for the Medicaid Expansion population. BCBSND administers the ND Medicaid Expansion network. Network providers contract with BCBSND, enroll with the State of North Dakota Medicaid program, and are located in the service area; the manual names FQHCs, RHCs and Indian Health Care Providers as network providers. Out-of-network services aren't covered without an approved referral. Traditional ND Medicaid is billed to the state under the FFS policy.",
    "claim_format": "n/a",
    "source_title": "Blue Cross Blue Shield of North Dakota - Medicaid Expansion Provider Manual (BND-21-0027967, 6-26)",
    "source_url": "https://www.bcbsnd.com/content/dam/bcbsnd/documents/manuals/Medicaid-Expansion-Provider-Manual.pdf",
    "source_section": "Glossary - Network provider; Out-of-network services (p.71-72)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the manual describes the Expansion network; the scope of non-Expansion managed care was not separately confirmed from a state source.",
    "id": "ND-225",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "Medicaid Expansion - Blue Cross Blue Shield of North Dakota (BCBSND)",
    "payer_type": "Managed Medicaid",
    "category": "Claim form / submission",
    "codes": "837P; 837I; Payer ID 55891",
    "question": "How and when do I file ND Medicaid Expansion claims with BCBSND?",
    "answer": "File all professional (837P) and institutional (837I) claims electronically to BCBSND, payer ID 55891. Deadlines: 180 days from the date of service for Expansion-only claims; 180 days from notice of the member's retroactive coverage; 365 days from the date of service when there is third-party liability. Use frequency type 1 for an initial claim. Late claims are denied unless BCBSND caused the error.",
    "claim_format": "837P / 837I (electronic)",
    "source_title": "Blue Cross Blue Shield of North Dakota - Medicaid Expansion Provider Manual (BND-21-0027967, 6-26)",
    "source_url": "https://www.bcbsnd.com/content/dam/bcbsnd/documents/manuals/Medicaid-Expansion-Provider-Manual.pdf",
    "source_section": "How to file and correct claims - Claim submission: time frames (p.49)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "ND-226",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "North Dakota",
    "payer": "Medicaid Expansion - Blue Cross Blue Shield of North Dakota (BCBSND)",
    "payer_type": "Managed Medicaid",
    "category": "Billing rules / incident-to",
    "codes": "",
    "question": "Does BCBSND (ND Medicaid Expansion) have FQHC-specific encounter billing rules?",
    "answer": "The BCBSND manual has no FQHC encounter or PPS billing section; payment follows the provider's participation agreement. It says BCBSND doesn't recognize Medicare's incident-to billing. When BCBSND is primary, RHC services are filed on the 837P under the individual NPI, not an 837I under the RHC number. The manual doesn't say whether FQHCs follow the same instruction.",
    "claim_format": "Per participation agreement",
    "source_title": "Blue Cross Blue Shield of North Dakota - Medicaid Expansion Provider Manual (BND-21-0027967, 6-26)",
    "source_url": "https://www.bcbsnd.com/content/dam/bcbsnd/documents/manuals/Medicaid-Expansion-Provider-Manual.pdf",
    "source_section": "Rural Health Clinic; Incident to billing (p.41)",
    "last_verified": "2026-10-30",
    "confidence": "Low - FQHC-specific claim rules aren't stated; confirm with BCBSND Provider Services or your contract.",
    "id": "ND-227",
    "region": "Region 8",
    "state_abbr": "ND"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "PPS visit codes (Appendix); T1015",
    "question": "How do I get reimbursed for office visits for South Dakota Medicaid?",
    "answer": "Most FQHC services are paid per visit as a single per diem PPS payment covering everything tied to the visit. A visit is a face-to-face or telehealth encounter with an eligible provider. Only codes on the manual's Appendix list of PPS visit codes generate the per diem; services in the PPS table aren't separately billable. Unusually, South Dakota has FQHCs bill PPS services on the CMS-1500 or 837P, at usual and customary charges.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "FQHC/RHC Overview; FQHC/RHC PPS Services (p.3); PPS Reimbursement (p.9); Claim Instructions (p.13); Appendix (p.17+)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-228",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Claim form / submission",
    "codes": "CMS-1500; 837P",
    "question": "Which claim form does a South Dakota FQHC use?",
    "answer": "The CMS-1500 or 837P, for both PPS and non-PPS services. Bill PPS services under the FQHC's NPI. That includes physicians or other licensed practitioners employed or contracted by the FQHC who work inside the clinic. Non-PPS services must go on a separate claim under a separately enrolled billing NPI and taxonomy that isn't recognized as an FQHC/RHC, with the servicing provider and taxonomy listed. Dental claims may only use codes on the dental fee schedules.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Claim Instructions - PPS Services; Non-PPS Special Instructions (p.13-14)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-229",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Qualifying visit / practitioners",
    "codes": "",
    "question": "Which practitioners can generate a PPS encounter at a South Dakota FQHC?",
    "answer": "Dentist, NP, physician, nurse midwife, PA, psychologist, CSW-PIP and CSW-PIP candidate, LPC-MH and LPC working toward the MH designation, Clinical Nurse Specialist - Mental Health, LMFT, other qualified providers giving a vaccine at a standalone visit, DBH-accredited SUD agencies, and visiting nurses (RN or LPN). RNs and LPNs can't enroll with SD Medicaid. Dietitians, nutritionists, ABA providers, SLPs, OTs and PTs can't enroll as FQHC servicing providers. The FQHC billing NPI must be enrolled with Medicare as an FQHC; stand-alone FQHC dental clinics are exempt.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Eligible Providers - FQHC/RHC PPS Services (p.1)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-230",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "Modifier 25; T1015",
    "question": "Can a South Dakota FQHC be paid for two visits on the same day?",
    "answer": "Up to two per day. Multiple professionals or encounters on one day are a single visit, but a second visit is paid at PPS if: a new illness or injury arises after the first visit; one service is a complete comprehensive EPSDT screen; one visit is behavioral health (ARSD 67:16:41 or 67:16:48); or one visit is dental. Bill the two visits on separate claims. For two E/M services, or an E/M plus a preventive visit, put modifier 25 on the code on both claims. When psychotherapy (90832, 90834, 90837, 90791, 90792) is billed as a different encounter on the same day, bill T1015 in place of the E/M code.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Multiple Visits; Billing for Multiple Visits (p.8); Multiple Same Day Visits (p.13-14)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-231",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Incident-to services",
    "codes": "",
    "question": "What counts as incident-to (not separately billable) at a South Dakota FQHC?",
    "answer": "These are included in PPS and are never a stand-alone visit: drugs and biologicals not usually self-administered; venipuncture; supplies; auxiliary staff services; BP checks; allergy injections; prescriptions; nursing services; diabetes education; medical nutrition therapy; and SLP, PT and OT. The one exception is a standalone vaccine visit. Don't unbundle services normally given in one visit to create extra encounters, or ask patients to come back without medical necessity.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "FQHC/RHC PPS Services table (p.3-5); Incidental Services; Unbundling Services (p.5-6)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-232",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services outside PPS",
    "codes": "J7296-J7307 (LARC); 99188; 0500F; lab; technical components",
    "question": "Which South Dakota FQHC services are paid on top of, or outside, the PPS rate?",
    "answer": "Paid on top of PPS, billed on the PPS claim under the FQHC NPI: LARC/IUD codes J7296, J7297, J7298, J7300, J7301, J7306 and J7307 (with the NDC); fluoride varnish 99188 on the same day as an encounter (ages 20 and under, up to 3 per July-June benefit year; D1206 isn't billable on the CMS-1500); and initial prenatal visit reporting 0500F, within 15 days. Non-PPS services go under the separate non-FQHC NPI at the lower of charges or the fee schedule. These include technical components (x-ray, ultrasound, EKG), lab (venipuncture stays in PPS), DME, prosthetics, practitioner services in hospitals or ASCs, remote patient monitoring, transportation and hospice.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "FQHC/RHC Non-PPS Services (p.6-7); LARC, Fluoride Varnish, Initial Prenatal Visit Reporting (p.10); Claim Instructions (p.13)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-233",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Vaccines",
    "codes": "",
    "question": "Can a South Dakota FQHC bill a standalone vaccine visit?",
    "answer": "Yes. A standalone vaccine visit, with its administration code, is paid at the PPS encounter rate. When a vaccine is given incidental to a medical encounter, it's included in that encounter's rate, but must still be listed on the claim for data collection. Vaccines may not be scheduled on a separate day just to increase payment. Pediatric vaccination counseling is part of the encounter; it can be billed fee-for-service under the separate NPI only if no encounter happened that day.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Standalone Vaccines/Immunizations; Pediatric Vaccination Counseling (p.7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-234",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Obstetric / prenatal",
    "codes": "TH modifier; 59430; 0500F",
    "question": "How should a South Dakota FQHC bill prenatal and postpartum care?",
    "answer": "Itemize prenatal care using the applicable E/M code with a pregnancy diagnosis. Since April 1, 2024, add the TH modifier to prenatal E/M codes, except on the visit that confirmed the pregnancy. Bill postpartum visits with 59430. Don't bill duplicate services, for example prenatal E/M visits plus the global delivery code. Report the initial prenatal visit with 0500F within 15 days.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Obstetric Services (p.5); Initial Prenatal Visit Reporting (p.10)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-235",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health / SUD",
    "codes": "H0001, H0004, H0005, T1006, H0050 (HF modifier)",
    "question": "How are behavioral health and SUD services paid at a South Dakota FQHC?",
    "answer": "Mental health services by the eligible MH providers are PPS visits. Group psychotherapy and multiple-family group psychotherapy aren't covered. SUD treatment needs enrollment as a DBH-accredited SUD agency. These codes, with the HF modifier, are paid at PPS: H0001, H0004, H0005, T1006 and H0050. Group counseling is paid at 28% of the PPS rate, and lines without HF are denied. Group counseling plus another SUD encounter on the same day are both payable, on separate claims. MAT counts as a medical encounter.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "PPS Services table (p.4-5); Substance Use Disorder Treatment Reimbursement (p.10); Quick Answers 5-6 (p.15)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-236",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Services away from center",
    "codes": "",
    "question": "Where can South Dakota FQHC visits take place?",
    "answer": "At the FQHC, the recipient's residence (including assisted living), a skilled nursing facility, or the scene of an accident. Not in an inpatient or outpatient hospital department (including a CAH), or a facility whose requirements preclude FQHC visits. Practitioner services at hospitals and ASCs are non-PPS and billed under the separate NPI.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "FQHC/RHC Services Locations (p.7-8); Non-PPS Services (p.6)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-237",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "",
    "question": "Can a South Dakota FQHC bill telehealth?",
    "answer": "Yes. FQHCs can be the originating site and can also provide distant-site telemedicine, and the definition of a visit includes telehealth encounters. Bill the originating-site fee under the FQHC NPI; payment is capped at the Physician Services fee schedule amount. Modifier and POS details are in SD's separate Telemedicine manual, which wasn't reviewed here.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Telemedicine (p.7); Telemedicine Originating Site Fee (p.9, p.13); Definitions (p.14)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - modifier/POS details live in the separate Telemedicine manual (not reviewed).",
    "id": "SD-238",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "APM (alternative payment)",
    "codes": "",
    "question": "Does South Dakota offer an FQHC alternative payment methodology?",
    "answer": "Yes, from July 1, 2026, FQHCs can elect an APM. It pays enhanced encounter rates based on statewide cost-based weighted-average rates, and never less than the FQHC's PPS rate. Starting July 1, 2027, APM rates rise each year by the Medicare Economic Index for primary care. Medical and dental APMs are re-evaluated at least every 5 years. To elect it, submit the APM Election Form to the Department in writing. The manual doesn't list rate amounts.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "FQHC Alternative Payment Methodology (APM) (p.9)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-239",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report",
    "codes": "CMS-224-10",
    "question": "Does a South Dakota FQHC have to file a Medicaid cost report?",
    "answer": "Yes. Under ARSD 67:16:44:05, file an annual cost report with actual costs and total visits to the DSS Office of Provider Reimbursements and Audits. The CMS-224-10 is acceptable, and it's due within five months after the fiscal year ends. FQHC dental providers must also file a Dental Supplemental Cost Report at the same time.",
    "claim_format": "n/a",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Cost Report; Dental Supplemental Cost Report (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-240",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How does a South Dakota FQHC request a PPS change in scope?",
    "answer": "A change in scope is adding or removing a service in the per diem base, or certain changes in type, intensity, duration or amount that change cost per encounter by at least 5%. Examples: adding or removing specialty providers, switching between mid-levels and physicians, equipment changes, or a patient mix needing more intensive care. Cost increases, volume changes, new sites with the same services, and ownership changes don't qualify. File once the change has existed for six full months and within 9 months of it, using the Change in Scope Request form with a narrative, attestation, cost reports from before and after, and projected encounters. Only one adjustment is made per year. The new rate is effective 30 days after the request is received. Appeals go to the Office of Administrative Hearings within 30 days.",
    "claim_format": "n/a",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Change in Scope of Services (p.11-13)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-241",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing / records",
    "codes": "",
    "question": "What is South Dakota Medicaid's timely filing limit for FQHC claims?",
    "answer": "SD Medicaid must receive the completed claim within 6 months after the month of service. Reconsiderations are considered only if received within the timely filing period or within 3 months of the denial. Keep records for at least 6 years after the claim was last paid or denied.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Timely Filing (p.9); Documentation Requirements (p.8)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-242",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "CHW / case management",
    "codes": "T1017",
    "question": "Can a South Dakota FQHC bill community health worker or justice-involved youth case management services?",
    "answer": "For CHW services, the FQHC must enroll separately as a CHW Agency; payment is the lesser of usual and customary or the CHW fee schedule. Targeted case management (T1017) for eligible adjudicated juveniles within 30 days of release from a carceral setting is paid at the lesser of usual and customary or that program's fee schedule.",
    "claim_format": "CMS-1500 / 837P",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Community Health Worker (CHW) Services; Targeted Case Management for Justice Involved Youth (p.7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "SD-243",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "South Dakota",
    "payer": "South Dakota Medicaid (DSS fee-for-service)",
    "payer_type": "Medicaid FFS",
    "category": "Managed care status",
    "codes": "",
    "question": "Does South Dakota Medicaid use MCOs for FQHC claims?",
    "answer": "The South Dakota FQHC manual describes only billing South Dakota Medicaid directly. It has no managed care organization or MCO wraparound provisions, so FQHC claims go to SD Medicaid under the fee-for-service rules above.",
    "claim_format": "n/a",
    "source_title": "South Dakota Medicaid Billing and Policy Manual - FQHC and RHC Services (updated September 2026)",
    "source_url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Professional/FQHC_and_RHC.pdf",
    "source_section": "Reimbursement and Billing; Claim Instructions (p.9-14)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - no-MCO status is inferred from the manual's silence; not a direct statement.",
    "id": "SD-244",
    "region": "Region 8",
    "state_abbr": "SD"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Billing codes / claim form",
    "codes": "CPT/HCPCS",
    "question": "How do I code FQHC services for Utah Medicaid?",
    "answer": "The FQHC manual says to report delivered services with the appropriate CPT codes and points to Section I, Chapter 11 for billing instructions. Neither manual says whether FQHC encounters go on the professional (837P) or institutional (837I) claim, so check with Utah Medicaid before setting up claims.",
    "claim_format": "Not stated (see note)",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "11 Billing; 11-1 Billing code (p.9)",
    "last_verified": "2026-10-30",
    "confidence": "Low - the manuals don't name the FQHC claim form; verify with Utah Medicaid",
    "id": "UT-245",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "",
    "question": "Can a Utah FQHC bill more than one encounter per day?",
    "answer": "No. The manual limits reporting to one encounter per patient per day. Seeing more than one health professional, or seeing the same professional more than once that day, still counts as one visit. You may bill up to, but not more than, your established encounter rate.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "9-2 Limitations (p.9)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-246",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "What's in the encounter rate",
    "codes": "",
    "question": "What does the Utah FQHC encounter rate cover?",
    "answer": "Each clinic has its own encounter rate. It is a blended rate of all service costs, excluding carve-out services. If you itemize several services for one patient at one location on the same day, Medicaid still pays the encounter rate, whatever the claim total.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "9-2 Limitations (p.9)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-247",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Covered FQHC services",
    "codes": "",
    "question": "What services does Utah Medicaid cover at an FQHC?",
    "answer": "Mainly outpatient services, including routine diagnostic and lab services from a qualified health professional. The list includes preventive primary care, screening tests and bone mass measurement. It also covers incident-to services and supplies, including drugs that can't be self-administered, and basic CLIA-compliant lab work. Visiting nurse services in home health shortage areas and other state plan ambulatory services are covered too. FQHCs must provide preventive services onsite or by arrangement: well-child care, pediatric eye, ear and dental screening, mental health and SUD referrals, enabling services, prenatal care, family planning and immunizations. DSMT is part of the face-to-face encounter and can't be billed separately.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "8-3 Covered Services (pp.5-7)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-248",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Non-covered services",
    "codes": "",
    "question": "What isn't covered at a Utah FQHC?",
    "answer": "Not covered: visiting nurse personal care, homemaker or chore services, and generally the technical component of lab and diagnostic services, with some preventive exceptions. For FQHCs specifically, the list includes group or mass information programs, health education classes and group education. Eyeglasses, hearing aids, ambulance, prosthetics and DME are also excluded.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "9-1 Non-covered services (p.8)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-249",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Obstetrical care",
    "codes": "TH modifier",
    "question": "How do Utah FQHCs bill prenatal and postpartum visits?",
    "answer": "Report each antepartum and postpartum visit with an E/M code and the TH modifier on that service line. For labor and delivery, report only the CPT code for the delivery mode. Inpatient postpartum care uses the post-delivery or discharge E/M code with TH.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "11-3 Obstetrical Care (p.10)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-250",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Mobile units / sites",
    "codes": "",
    "question": "Does each Utah FQHC site or mobile unit need its own enrollment?",
    "answer": "Following Medicare, each permanent FQHC site needs its own agreement. Mobile units of an approved site don't have to enroll or bill separately, but they must meet Medicare health and safety standards.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "11-2 Mobile units (p.9)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-251",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Rate setting / PPS",
    "codes": "",
    "question": "How are Utah FQHC PPS rates set and updated?",
    "answer": "The PPS rate is a per-visit amount: a clinic's reasonable Medicaid costs divided by its Medicaid visits. It increases each year by the MEI for primary care and is adjusted for changes in scope of services. Utah also makes quarterly interim payments, no later than 30 days after each quarter ends, based on the latest annual reconciliation, and settles annual reconciliations as needed.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "13 Reimbursement; 13-1 Prospective payment system (p.10)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-252",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Alternative payment method (APM)",
    "codes": "",
    "question": "Can a Utah FQHC choose an alternative payment method?",
    "answer": "Yes. FQHCs (but not RHCs) can elect the APM if it pays at least what PPS would. Utah takes Medicaid allowable costs times the Medicaid charge percentage, makes interim payments from billed charges and pays whichever is greater, APM or PPS. To change methods for a later year, give written notice at least 30 days before your fiscal year starts.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "13-3 Alternative payment method for FQHCs (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-253",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Cost report / settlement (APM)",
    "codes": "",
    "question": "When are Utah APM cost reports due and how is settlement done?",
    "answer": "APM FQHCs must send their annual cost report and supporting cost information, including their own estimate of the settlement, within six months after the fiscal year ends. The Department may make a preliminary payment. It reviews or audits the report and makes a final settlement within 12 months after year end, which picks up late claims and adjustments. TPL collections reduce the final settlement. Overpayments must be repaid, and underpayments are paid to the FQHC.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "13-3 Alternative payment method for FQHCs (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-254",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Behavioral health billing",
    "codes": "",
    "question": "Who do Utah FQHCs bill for mental health and SUD services?",
    "answer": "Bill Utah Medicaid (DIH) directly, even when the member is in a Prepaid Mental Health Plan (PMHP) or a Utah Medicaid Integrated Health (UMIC) plan (the manual's wording). Medical services go to the member's ACO, or to Utah Medicaid if the member has no ACO.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "13-2 Mental Health and Substance Use Disorder Services (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-255",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth",
    "codes": "POS 02/10; GT",
    "question": "How do I bill telehealth for Utah Medicaid?",
    "answer": "Distant-site providers on professional claims (837P) use POS 02 or 10 with the usual codes. On institutional claims (837I), add the GT modifier (interactive audio and video). Telehealth has the same thresholds, prior authorization and rates as in-person care. There are no geographic limits, and audio-only may be used when appropriate. Follow HIPAA and UHIN telehealth standards. The originating site gets no extra payment. The FQHC manual refers to Section I for telehealth and doesn't explain how it interacts with the encounter rate.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "8-4.2 Telehealth; 8-4.2.2 Billing; 8-4.2.3 Limitations (pp.81-83)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - general rule; FQHC encounter treatment of telehealth isn't stated",
    "id": "UT-256",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing",
    "codes": "",
    "question": "What is Utah Medicaid's timely filing limit?",
    "answer": "365 days from the date of service, or from the 'end' date on institutional span claims. Adjustments and corrections have the same limit. You can request review of untimely claims only for the listed exceptions, with documentation and the Timely Filing Document Submission Form.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "11-6.4 Time Limit to Submit Medicaid Claims (pp.112-113)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-257",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossover / TPL",
    "codes": "",
    "question": "What are Utah's crossover deadlines for dual-eligible patients?",
    "answer": "Crossover claims are due within 365 days of the date of service or six months after Medicare's decision. Put the Medicaid provider's NPI on the claim. You can't make a Medicaid member with Medicare 'private pay'. Accept the patient as a Medicaid member and follow the TPL billing rules.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "Medicare/Medicaid Crossover Claims (p.106)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-258",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid fee-for-service (DHHS Division of Integrated Healthcare)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "",
    "question": "Can Utah FQHCs provide dental services?",
    "answer": "Yes, but the member's eligibility type limits which providers can do dental work. See Chapter 8 of the Dental, Oral Maxillofacial and Orthodontia Services provider manual. ACOs don't cover dental.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "8-3.1 Dental coverage (p.7); Section I 2-7 (p.30)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-259",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid managed care (ACOs, PMHPs, HOME)",
    "payer_type": "Managed Medicaid",
    "category": "Managed care overview",
    "codes": "",
    "question": "How does Utah Medicaid managed care work?",
    "answer": "DIH pays monthly premiums to managed care entities (MCEs). ACOs cover physical health and some drugs. PMHPs, run by county mental health and SUD authorities and assigned by county, cover behavioral health. HOME covers both. The four ACOs are Health Choice Utah, Healthy U, Molina Healthcare and Select Health Community Care, with 2 to 4 in each county. ACO enrollment is required for most members in Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington and Weber counties. Elsewhere, members can stay fee-for-service.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "2 Managed Care Entities; 2-1; 2-7 Accountable Care Organizations (pp.24-30)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-260",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid managed care (ACOs, PMHPs, HOME)",
    "payer_type": "Managed Medicaid",
    "category": "MCO wraparound / supplemental",
    "codes": "",
    "question": "How does Utah make up the difference between ACO payments and PPS?",
    "answer": "The Department estimates the gap between what ACOs paid the clinic and what the clinic is owed under PPS, and pays it quarterly as a supplemental payment. Annual reconciliation settles it as needed.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Rural Health Clinics and Federally Qualified Health Centers Services (Updated November 2025)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Rural%20Health%20Clinic%20And%20FQHC/RHC_FQHC.pdf",
    "source_section": "13-1 Prospective payment system (p.10)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-261",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid managed care (ACOs, PMHPs, HOME)",
    "payer_type": "Managed Medicaid",
    "category": "MCE carve-outs",
    "codes": "",
    "question": "Which services are carved out of Utah MCEs and billed to Medicaid FFS?",
    "answer": "If a member is in an MCE, DIH pays only for carve-out services. The carve-out list includes:\n- autism services\n- early intervention\n- transportation\n- certain psychological testing\n- hospital or ASC facility charges for dental\n- HCBS waiver services\n- methadone administration\n- several drug classes (for example antipsychotics and antidepressants)\n- other listed items\n\nACOs also don't cover behavioral health or dental. See the full list in Section I 2-6.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "2-6 MCE Carve-Out Services; 2-7 (pp.28-30)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-262",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid managed care (ACOs, PMHPs, HOME)",
    "payer_type": "Managed Medicaid",
    "category": "PMHP members at FQHCs",
    "codes": "",
    "question": "Do Utah PMHP members need PMHP authorization to get behavioral health at an FQHC?",
    "answer": "No. PMHP members can go directly to an FQHC, PMHP prior authorization isn't required, and the FQHC may bill DIH. The FQHC manual also says to bill BH services to Utah Medicaid for PMHP and UMIC members.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "2-8 Prepaid Mental Health Plans (p.32); FQHC manual 13-2 (p.11)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-263",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Utah",
    "payer": "Utah Medicaid managed care (ACOs, PMHPs, HOME)",
    "payer_type": "Managed Medicaid",
    "category": "HOME program",
    "codes": "",
    "question": "What is Utah's HOME program?",
    "answer": "Healthy Outcomes Medical Excellence (HOME) is a voluntary MCE run by the University of Utah for members who have a developmental disability and mental health or behavioral challenges. It covers what the ACO and PMHP would cover, except pharmacy. Members who enroll in HOME leave their ACO and PMHP. All MCEs cover emergency services 24/7, in or out of network.",
    "claim_format": "-",
    "source_title": "Utah Medicaid Provider Manual - Section I: General Information (Updated September 2026)",
    "source_url": "https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/All%20Providers%20General%20Information%20Section%20I/AllProvidersGeneralInfo_Section_1.pdf",
    "source_section": "2-9 HOME; 2-10 (p.32)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "UT-264",
    "region": "Region 8",
    "state_abbr": "UT"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Office visits / encounter payment",
    "codes": "T1015; rev 0520",
    "question": "How do I get reimbursed for office visits for Wyoming Medicaid?",
    "answer": "Bill the UB-04 / 837I with type of bill 77X and pay-to taxonomy 261QF0400X. Every claim needs at least two lines. The first is the encounter line: revenue code 0520 with T1015 at your total usual and customary charge. Then add $0.00 detail lines with a revenue and procedure code for each service, including the office visit or health check code. Medicaid pays the all-inclusive encounter rate and doesn't lower it when charges are less.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "Ch.14 FQHCs, 14.1.2-14.1.3 (pp.236, 238-239)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-265",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Same-day multiple visits",
    "codes": "",
    "question": "Can a Wyoming FQHC bill more than one encounter per day?",
    "answer": "Usually one encounter per member per day. More are paid when the member sees professionals of different specialties, or needs another visit for an unrelated illness or injury. A medical visit plus an 'other health' (behavioral health) visit on the same day can both be paid. Several same-specialty providers in one visit count as one encounter.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "14.1.1 Covered Services; 14.1.3 (pp.235, 238)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-266",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Billable visit definition",
    "codes": "",
    "question": "Which practitioners generate a billable FQHC visit in Wyoming?",
    "answer": "Medical visits are face-to-face visits with a physician, NP, nurse-midwife, PA, visiting nurse or dental professional; medical nutrition therapy and diabetes self-management training also count. Dental visits are with a dentist, orthodontist or a supervised dental team member. Other health visits are with a clinical psychologist, clinical social worker or other mental health professional. Services a practitioner provides outside the FQHC facility can't be billed under the FQHC NPI and go on an 837P under the practitioner's NPI. Members in the BCC or COLR benefit plans aren't covered in the FQHC setting.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "14.1 and 14.1.1 (pp.235-236)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-267",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "What's in the encounter rate",
    "codes": "",
    "question": "What is bundled into the Wyoming FQHC encounter rate?",
    "answer": "The rate covers everything provided during the encounter, including therapeutic and diagnostic services, tests, supplies, lab and radiology. The rule also bundles drugs that can't be self-administered, outreach, case management and transportation. These incidental services can't be billed as a stand-alone visit, even on another day.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Rules Chapter 37 - Federally Qualified Health Centers and Rural Health Clinics (048-37 Wyo. Code R.), read via the Cornell LII mirror; the official rules.wyo.gov viewer could not be fetched, and the 2018 filing on wyoleg.gov uses different section numbers",
    "source_url": "https://www.law.cornell.edu/regulations/wyoming/agency-048/subagency-0037/chapter-37",
    "source_section": "Ch.37 Sec. 5(b); Institutional Manual 14.1.2 (p.236)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "WY-268",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Dental",
    "codes": "ADA",
    "question": "How do Wyoming FQHCs bill dental?",
    "answer": "Bill dental services on the ADA dental claim form and follow the Wyoming Medicaid Dental Provider Manual. The institutional manual lists D8999 (orthodontics) and D9999 (dental) for FQHCs.",
    "claim_format": "ADA",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "14.1 (p.235)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-269",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "LARC",
    "codes": "J7296-J7307; 11981-11983",
    "question": "How do Wyoming FQHCs bill LARC devices?",
    "answer": "Bill the insertion visit on the UB-04 encounter claim (0520/T1015 plus $0 detail lines). Bill the device separately on a CMS-1500/837P under the practitioner group NPI, with the same date of service and an NDC (every LARC device code needs one). Bill your 340B acquisition cost, or usual and customary charges if you bought the device outside 340B. Payment is the lesser of billed amount or Medicaid allowed. Don't submit a device claim for removal-only visits.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "14.1.2 Billing for LARC (pp.236-238)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-270",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Rate setting / PPS",
    "codes": "",
    "question": "How are Wyoming FQHC PPS rates set?",
    "answer": "Wyoming uses a provider-specific PPS per-visit rate based on base-period (FY1999-2000) Medicaid allowable costs per 42 U.S.C. 1396a(bb). The rate is inflated forward each year by the MEI and adjusted for changes in scope of services. GME costs can be allowable. The current FQHC rate schedule is on the WDH fee schedule page.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Rules Chapter 37 - Federally Qualified Health Centers and Rural Health Clinics (048-37 Wyo. Code R.), read via the Cornell LII mirror; the official rules.wyo.gov viewer could not be fetched, and the 2018 filing on wyoleg.gov uses different section numbers",
    "source_url": "https://www.law.cornell.edu/regulations/wyoming/agency-048/subagency-0037/chapter-37",
    "source_section": "Sec. 6 and Sec. 7 (General Reimbursement Methodology; Payment on/after Jan 1, 2001)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "WY-271",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Change in scope",
    "codes": "",
    "question": "How do I request a change in scope of service in Wyoming?",
    "answer": "Send WDH written notice of the increase or decrease in services, with a settled Medicare cost report that documents the change and backs up its costs. WDH looks at the type, intensity, duration and amount of the new or discontinued service and at whether costs are reasonable. A cost change alone isn't a scope change. WDH can ask for more documentation before it considers the request.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Rules Chapter 37 - Federally Qualified Health Centers and Rural Health Clinics (048-37 Wyo. Code R.), read via the Cornell LII mirror; the official rules.wyo.gov viewer could not be fetched, and the 2018 filing on wyoleg.gov uses different section numbers",
    "source_url": "https://www.law.cornell.edu/regulations/wyoming/agency-048/subagency-0037/chapter-37",
    "source_section": "Sec. 7(b)(iv)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "WY-272",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "New FQHC rates",
    "codes": "",
    "question": "How is a new Wyoming FQHC's Medicaid rate set?",
    "answer": "Submit a settled or as-filed Medicare cost report, or cost and visit estimates if you don't have one. The interim rate is 100% of the reasonable costs of FQHCs with similar caseloads, or the statewide average if there are none, adjusted by MEI. Once a settled cost report comes in, WDH recalculates the rate using your first Medicaid fiscal year as the base. There's no retroactive settlement of under- or overpayments. Out-of-state FQHCs get the statewide average payment as of October 1.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Rules Chapter 37 - Federally Qualified Health Centers and Rural Health Clinics (048-37 Wyo. Code R.), read via the Cornell LII mirror; the official rules.wyo.gov viewer could not be fetched, and the 2018 filing on wyoleg.gov uses different section numbers",
    "source_url": "https://www.law.cornell.edu/regulations/wyoming/agency-048/subagency-0037/chapter-37",
    "source_section": "Sec. 8 and Sec. 9",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "WY-273",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Telehealth / virtual",
    "codes": "GT or 95; Q3014",
    "question": "How do I bill telehealth for Wyoming Medicaid at an FQHC?",
    "answer": "FQHCs can be originating (spoke) sites and bill Q3014, paid at the lesser of charge or the Medicaid fee. Q3014 isn't billable when the member uses their own phone, tablet or computer. The distant site bills the service with modifier GT or 95, at the same codes and rates as in person. Telehealth must be real-time interactive audio and video; phone calls, email and fax don't count. Get telehealth consent when the originating site is the member's home.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "Ch.6, 6.23 Telehealth (pp.130-134)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - this is the general telehealth section; it doesn't say how FQHC encounter rates apply to distant-site services",
    "id": "WY-274",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Timely filing",
    "codes": "",
    "question": "What is the Wyoming Medicaid timely filing limit?",
    "answer": "Submit a clean claim within 12 months (365 days) of the date of service. Medicare crossovers are due within 12 months of the date of service or 6 months (180 days) from the EOMB payment date, whichever is later. For retroactive eligibility, file within 6 months of the eligibility decision and attach the notice.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "Ch.6, 6.19 Timely Filing and 6.19.1 Exceptions (pp.127-128)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-275",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Medicare crossovers / TPL",
    "codes": "",
    "question": "How do Wyoming FQHC claims handle other insurance and Medicare?",
    "answer": "For encounter claim types (RHC, FQHC, IHS, ESRD), TPL and Medicare payments go on the detail lines, not the encounter line, with CARCs and group codes. When Medicare is primary, bill under Medicare's rules and codes.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "7.3 Billing Requirements - UB-04 TPL/Medicare instructions; 14.1.3 (p.239)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-276",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Copays",
    "codes": "",
    "question": "Do Wyoming Medicaid copays apply at FQHCs?",
    "answer": "Yes, with exceptions. FQHC encounters (T1015 with revenue code 0520) are on the manual's $3.65 co-payment schedule. Exempt groups include children (Medicaid under 21; Kid Care CHIP under 19, except CHIP Plans B and C) and nursing facility residents; check the manual's full exception list.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Institutional (UB-04) Provider Manual, v20.0 eff. 2026-10-01 (Acentra Health / WDH)",
    "source_url": "https://wyomingmedicaid.com/portal/References/latestproviderfiles/BMS_Acentra%20Health_Institutional%20Provider%20Manual_N_2026.10.01_v20.0.pdf",
    "source_section": "Ch.6, 6.11 Co-Payment Schedule (pp.87-88)",
    "last_verified": "2026-10-30",
    "confidence": "High - read directly in the cited source.",
    "id": "WY-277",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "Wyoming Medicaid fee-for-service (WDH / Acentra Health)",
    "payer_type": "Medicaid FFS",
    "category": "Multiple sites",
    "codes": "",
    "question": "Does each Wyoming FQHC site need separate Medicaid approval?",
    "answer": "Yes. Each permanent site is approved as a provider on its own, unless CMS has approved running both locations under one provider number. A satellite location has to share medical, office and/or administrative staff with the main site.",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Medicaid Rules Chapter 37 - Federally Qualified Health Centers and Rural Health Clinics (048-37 Wyo. Code R.), read via the Cornell LII mirror; the official rules.wyo.gov viewer could not be fetched, and the 2018 filing on wyoleg.gov uses different section numbers",
    "source_url": "https://www.law.cornell.edu/regulations/wyoming/agency-048/subagency-0037/chapter-37",
    "source_section": "Sec. 5(c)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - text read in the Cornell LII mirror of the official rule; the official state rule viewer could not be fetched by our checker, so confirm against the official text.",
    "id": "WY-278",
    "region": "Region 8",
    "state_abbr": "WY"
  },
  {
    "state": "Wyoming",
    "payer": "No comprehensive Medicaid MCOs (CME program via Magellan only)",
    "payer_type": "Managed Medicaid",
    "category": "Plans / MCO overview",
    "codes": "",
    "question": "Does Wyoming have Medicaid managed care plans for FQHC billing?",
    "answer": "Not for acute or primary care. FQHC claims go to Wyoming Medicaid fee-for-service. The only managed care entity is the Care Management Entity (CME) program for high-need youth, run by Magellan Healthcare. It provides targeted case management only, not acute care. It became a non-risk fee-for-service model on July 1, 2018 (it was a capitated PAHP before).",
    "claim_format": "UB-04 / 837I",
    "source_title": "Wyoming Dept. of Health - SFY 2024 Care Management Entity (CME) External Quality Review Report (April 2025)",
    "source_url": "https://health.wyo.gov/wp-content/uploads/2025/04/SFY-2024-WY-CME-EQR-Report_Final.pdf",
    "source_section": "Executive summary and Background (pp.5-7)",
    "last_verified": "2026-10-30",
    "confidence": "Medium - the EQR says the CME is the managed care program; the absence of comprehensive MCOs is inferred from state documents",
    "id": "WY-279",
    "region": "Region 8",
    "state_abbr": "WY"
  }
]