Tribal Federally Qualified Health Center (Tribal FQHC) reimbursement option
Describes Alaska Medicaid policy establishing a Tribal FQHC provider type, reimbursement options, off-site service rules, enrollment mechanics, and interactions with Community Behavioral Health Centers and other provider types. Applies to Tribal outpatient programs, CHA/BHA/DHATs, and Tribal Clinics in Alaska.
No material clinical or coverage changes in this revision.
Coverage and Reimbursement Criteria for Tribal FQHCs
Reimbursement methodologies and off-site service coverage
Tribal FQHCs may elect among three payment methodologies; off-site services and certain provider types have specific coverage rules.
ANY of the following
- IHS-AIR Alternative Payment Methodology
Available only to Tribal FQHCs; matched to the IHS‑OMB All‑Inclusive Rate; no cost reports required.
- Alaska Medicaid PPS FQHC Rate
Statewide PPS rate; providers electing this rate must submit annual FQHC cost reports to the DOH Office of Rate Review (ORR).
- Facility‑Based Medicaid FQHC APM
Facility‑specific cost‑based APM requiring submission of facility cost reports; ORR needs two full years of reports and desk review may delay a cost‑based rate for ~3–4 years; provider will receive PPS rate while waiting.
ALL of the following
- Tribal FQHCs may provide and bill for services furnished off‑site, including temporary locations and services provided in another community or at one‑time/occasional sites (e.g., health fairs, schools, fish camps).
Eligible off‑site services furnished on or after Nov 1, 2021 are reimbursable; federal enforcement/grace period for clinic four‑walls extended through Feb 11, 2025.
ALL of the following
- These providers are not treated as 'clinic' providers subject to the four‑walls restriction and may provide off‑site services via appropriate Health Professional Group or dental group enrollments.
ALL of the following
- Rehabilitation and 1115 waiver services (including autism services classified as rehabilitative) are not impacted by the four‑walls rule and may be provided off‑site and reimbursed accordingly.
ALL of the following
- Behavioral health services are covered when provided by authorized behavioral health clinicians employed by an FQHC and working within their scope (e.g., psychologist, LCSW, LMFT, LPC); specific CPTs are listed in the billing manual/fee schedules.
ALL of the following
- Under PPS or facility‑based methodologies, generally one encounter per recipient per facility per day (e.g., one medical, one dental, one behavioral health visit per day).
- IHS AIR follows tribal clinic policy and may allow generally one medical, one dental, and one behavioral health visit per recipient per facility per day as applicable.
ALL of the following
- New Tribal FQHC enrollments may request retroactive enrollment up to one year to cover eligible off‑site services furnished prior to enrollment; providers should hold claims until enrollment is finalized.
ALL of the following
- Each permanent site must enroll separately; a facility may not be dually enrolled as a Tribal Clinic and a Tribal FQHC simultaneously (conversion for existing Tribal Clinic enrollments is prospective and cannot be backdated).
ALL of the following
- Dental services (DHAT) must bill through the dental group; pharmacy coverage applies if the TFQHC is enrolled as a dispensing provider; certain services (e.g., nurse‑midwife L&D) may be carved out and billed via HPG as specified.
TFQHC coverage criteria
Coverage and reimbursement determinations for TFQHC services are as follows:
ALL of the following
- Conversion from an existing Tribal Clinic to a TFQHC is prospective and cannot be backdated for existing enrollments; new enrollments at a new location may request a retroactive start date up to one year from the request to cover prior services.
ALL of the following
- To enroll as a TFQHC, enroll under tribal entity code 008 and select the TFQHC subspecialty; Medicare enrollment requirement removed by regulation but other FQHC requirements still apply.
ALL of the following
- Community Behavioral Health Centers (CBHCs) cannot convert their existing enrollment to TFQHCs; CBHCs seeking TFQHC status must complete a separate new enrollment process; facilities may be dually enrolled as TFQHC and CBHC via separate enrollments where permitted.
ALL of the following
- HRSA 330 grantees or HRSA FQHC Look‑Alikes operated by a tribe under the Self‑Determination Act qualify as Tribal FQHCs and may elect payment at the IHS AIR; becoming a Medicaid TFQHC does not create a relationship with HRSA programs.
Codes, Encounter Limits, and Provider Scope
| 90791 | Psychiatric diagnostic interview procedures |
| 90792 | Psychiatric diagnostic interview with medical services |
| 90832 | Individual psychotherapy, 30 minutes |
| 90834 | Individual psychotherapy, 45 minutes |
| 90837 | Individual psychotherapy, 60 minutes |
| 90839 | Psychiatric/behavioral health emergency service |
| 90847 | Family psychotherapy |
| 90853 | Group psychotherapy |
| 96156 | Health behavior assessment/intervention services |
| behavioral health service codes | Behavioral health service codes must be those identified in the billing manual and are reimbursed if the service is considered primary care and provided by a physician, physician assistant, or advanced practice registered nurse within the scope of their license (reimbursed at the elected TFQHC methodology). |
Enrollment, Conversion, Billing Holds, and Retroactive Requests
Submit TFQHC Conversion/Election form
Complete and submit the Tribal FQHC Conversion/Election form to notify the Department of an election to use the IHS-AIR APM or to convert between Tribal Clinic and Tribal FQHC enrollment.
Request retroactive enrollment (up to 1 year) and hold claims
Request retroactive enrollment for a new TFQHC enrollment for services furnished prior to enrollment for up to one year; hold claims from the date of conversion decision until enrollment is finalized to avoid denial or unreprocessed claims.
- Retroactive start date available up to one year from the enrollment request for new service locations.
- For existing Tribal Clinic conversions, enrollment cannot be backdated; providers must hold billing until conversion approval or claims will not be reprocessed.
Complete conversion/election and enroll as 008/Tribal Entity
Submit the TFQHC Conversion/Election form to change reimbursement methodology or to convert enrollment; enroll as 008/Tribal Entity and select the TFQHC sub-specialty to complete TFQHC enrollment.
- Use the Conversion/Election form available through the fiscal agent.
- Enroll using provider type code 008/Tribal Entity and select TFQHC subspecialty; comply with FQHC enrollment requirements except Medicare enrollment.
Hold billing during conversion until approval
When converting an existing Tribal Clinic enrollment to a TFQHC, hold billing from the date you decide to convert until conversion approval; conversions for existing enrollments cannot be backdated and claims billed during the hold will not be reprocessed.
- Converted enrollments retain the same provider ID and only the enrollment subspecialty is updated from Tribal Clinic to Tribal FQHC.
IHS-AIR reimbursement for offsite behavioral health services during federal grace period
Offsite community behavioral health rehabilitation services will be reimbursed at the IHS All-Inclusive Rate while permissible under the federal grace period, which ends February 11, 2025.
- Continue to refer to applicable fee schedules for covered services and rates while the federal grace period applies.
Key Terms and Enrollment Codes
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