ModifiedNevada Health AuthorityPolicy 2900

Federally Qualified Health Centers (FQHCs)

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Nevada Medicaid reimbursement, covered services, encounter limits, billing requirements, and non-covered services for Federally Qualified Health Centers and participating professionals and certified providers.

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Centers (FQHCs)

Policy CodePolicy 2900

Change TypeAdded doula services and provider type

Effective DateApril 1, 2022

Next Review DateN/A

Key ActionBill FQHC outpatient services using the applicable encounter methodology and limit claims to one reimbursable encounter per patient per day for each established SSPPS service type.

SourceLink

POLICY UPDATE CHANGES

Doula services are added to the list of services that may be included in FQHC medical encounters.

The chapter was reorganized and edited to standardize terminology, remove duplicative language, correct grammar and punctuation, and improve clarity.

3Encounter categories

1–3Maximum daily encounters

2Family-planning education reimbursements per year

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ModifiedNevada Health AuthorityPolicy 2900

Federally Qualified Health Centers (FQHCs)

Customize your policy alerts

Sign up for Nevada Health Authority Policy 2900 alerts

Get alerted when Policy 2900 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Centers (FQHCs)

Policy CodePolicy 2900

Change TypeAdded doula services and provider type

Effective DateApril 1, 2022

Next Review DateN/A

Key ActionBill FQHC outpatient services using the applicable encounter methodology and limit claims to one reimbursable encounter per patient per day for each established SSPPS service type.

SourceLink

POLICY UPDATE CHANGES

Doula services are added to the list of services that may be included in FQHC medical encounters.

The chapter was reorganized and edited to standardize terminology, remove duplicative language, correct grammar and punctuation, and improve clarity.

3Encounter categories

1–3Maximum daily encounters

2Family-planning education reimbursements per year

1Emergency denture reline maximum

6Maximum denture adjustments

Not requiredPrior authorization for FQHC encounters

FQHC Encounter Coverage

General FQHC Encounter Coverage

FQHC outpatient encounters are reimbursable when ALL of the following requirements are met:

ALL of the following

The service is medically necessary and provided at an FQHC.
The encounter includes preventive and/or primary health services and is categorized as medical, mental/behavioral health, or dental.
The service is furnished by an approved licensed Qualified Health Professional or certified provider within the FQHC's HRSA-approved scope of services and the practitioner's applicable state scope of practice.
The encounter is a face-to-face visit or encounter between the same patient and one or more approved providers on the same day for the same service type; multiple contacts with the same provider may comprise one encounter.
The FQHC bills using the applicable FQHC encounter reimbursement methodology.
The number of reimbursable encounters billed per patient per day does not exceed the number of established Service Specific Prospective Payment System (SSPPS) rates: one encounter with one rate, up to two with two rates, and up to three with three rates.

Medical Encounter Services

Medical encounters may be covered when provided by an employed or contracted approved provider under the FQHC's HRSA-approved scope of services and applicable state scope of practice.

Covered medical encounter services may include

Primary care services, including medical history, physical examination, health-status assessment, treatment of conditions amenable to ambulatory medical management, related supplies, and vital signs such as temperature, blood pressure, pulse, oximetry, and respiration.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening consistent with applicable policy and periodicity recommendations.
Preventive health services recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF), including education.
Home visits.
Family-planning services, including contraceptives; additional reimbursement for family-planning education on the same date of service is permitted up to two times per calendar year.

Specialized and Ancillary Service Requirements

Specialized and ancillary services are covered subject to the provider, service, scope-of-practice, encounter, and applicable program requirements below.

Specialized and ancillary service requirements

Behavioral/mental health encounter
- The service is provided by an employed or contracted Psychiatrist, Psychologist, APRN, PA, or LCSW authorized to provide mental/behavioral health services under the FQHC's HRSA-approved scope and the practitioner's applicable state regulatory-board scope of practice.
- The condition involves behavioral/mental health and/or substance use disorders, including co-occurring disorders, and the service consists of screening, assessment, diagnosis, treatment, or clinically appropriate evidence-based therapy, counseling, or medication management.
Dental encounter
- The service is provided by an employed or contracted Dentist or Registered Dental Hygienist under the FQHC's HRSA-approved scope and the practitioner's applicable regulatory-board scope of practice.

Non-Covered FQHC Encounter Services

The following services are not covered under the FQHC encounter reimbursement methodology:

Any of the following

Group therapy.
Eyeglasses.
Hearing aids.
Durable medical equipment, prosthetics, orthotics, and supplies.
Ambulance services.

Ancillary-Service Reimbursement

Ancillary services may be reimbursed in addition to an FQHC encounter when ALL of the following are met:

ALL of the following

The service is an approved Nevada Medicaid State Plan service but is not included within an approved FQHC encounter.
The service is provided by a licensed Qualified Health Professional and is otherwise eligible for reimbursement on the same date of service as the encounter.
The FQHC is enrolled within the appropriate provider type and meets all MSM coverage guidelines for the specific ancillary service.

FQHC and CCBHC Overlapping Services

When an FQHC is dually enrolled as a CCBHC, reimbursement must follow one coordinated delivery model for the service.

FQHC and CCBHC overlapping services

The FQHC and CCBHC maintain internal policies for appropriate treatment placement and select the model that billed medically appropriate services.
Medical necessity and clinical appropriateness, as determined by clinical professionals under care coordination, guide the selection when services overlap.
Primarily CCBHC services that are not exclusively FQHC services are billed at the CCBHC PPS rate; primarily FQHC-specific services that are not exclusively CCBHC services are billed at the FQHC encounter rate.
Care coordination is required to prevent duplicative billing for the same service occurring at the same time.
The Medicaid Surveillance and Utilization Review unit may conduct retrospective review for billing duplication.

Medical Necessity and Prior Authorization

Reimbursement requires medical necessity and compliance with the applicable authorization pathway.

Medical necessity and authorization requirements

All services provided are medically necessary as defined in MSM Chapter 100 Medicaid Program.
The patient file contains documentation supporting the medical necessity of the services provided.
An FQHC encounter itself does not require prior authorization; prior-authorization requirements in referenced MSM chapters do not apply when the service is performed as an FQHC encounter.
An FQHC that is not contracted with a Managed Care Organization (MCO) follows the MCO's prior-authorization policy.
Ancillary services billed outside an encounter follow the prior-authorization guidelines applicable to the specific services provided.

Billing Codes and Encounter Limits

Covered Telehealth HCPCS CodesHCPCSCovered

HCPCS

Telehealth originating Healthcare Common Procedural Coding System (HCPCS) code billed by the originating encounter site when the originating and distant sites are two different encounter sites.

Daily Encounter Limit

Established SSPPS ratesOne

Daily reimbursement limitOne reimbursable encounter per patient per day

Applicable service typesEach reimbursable service type under the established encounter methodology

Daily Encounter Limit

Established SSPPS ratesTwo

Daily reimbursement limitUp to 2 reimbursable encounters per patient per day

Billing basis

Billing and Operational Requirements

Billing Rule

Encounter-Rate Billing and Daily Limits

Bill medically necessary FQHC services using the applicable outpatient encounter methodology. Encounters must include preventive and/or primary health services and are categorized as medical, mental/behavioral health, or dental; observe the daily limit based on the number of established SSPPS encounter rates.

One SSPPS rate: bill no more than one reimbursable encounter per patient per day.
Two SSPPS rates: bill no more than two reimbursable encounters per patient per day.
Three SSPPS rates: bill no more than three reimbursable encounters per patient per day.
An encounter is a same-day face-to-face visit or encounter with the same patient for the same service type, including multiple contacts with the same provider.

Billing Rule

Integral Laboratory and Radiology Services

Do not separately bill integral laboratory or radiology services conducted during the primary-care visit. These services are built into the established FQHC encounter rate.

Key Terms

FQHC Encounter

Encounter typeA face-to-face visit or encounter

ParticipantsA patient and one or more approved licensed Qualified Health Professionals and/or certified providers

Same-day ruleThe encounter takes place on the same day with the same patient for the same service type; multiple contacts with the same provider are included

Ancillary Services

Service statusAn approved Nevada Medicaid State Plan service

Exclusion from encounterNot included within an approved FQHC encounter

Reimbursement timing

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Centers (FQHCs)

Policy CodePolicy 2900

Change TypeAdded doula services and provider type

Effective DateApril 1, 2022

Next Review DateN/A

Key ActionBill FQHC outpatient services using the applicable encounter methodology and limit claims to one reimbursable encounter per patient per day for each established SSPPS service type.

SourceLink

On This Page

For women, annual preventive gynecological examinations, clinical breast examinations, thyroid function tests, and maternity care, including antepartum, labor and delivery, and postpartum care.

Vision and hearing screening.

Community Health Worker (CHW) services as defined in MSM Chapter 600.

Doula services as defined in MSM Chapter 600.

The FQHC bills a dental encounter for each face-to-face encounter for dental services.

The FQHC's in-office records substantially document the medical need.

Dentures provided by the FQHC are included in the daily encounter rate. Medicaid covers no more than one emergency denture reline and/or six adjustments, no more often than every six months beginning six months after the partial or denture purchase; prior authorization is not required for relines. Relines and adjustments within the first six months are prepaid with the prosthetic payment.

Telehealth encounter

The FQHC bills an encounter in lieu of an originating-site facility fee when the distant site provides ancillary services, such as a specialist consultation.
When the originating and distant sites are different encounter sites, the originating site bills the telehealth originating HCPCS code and the distant site may bill the encounter code.

Ancillary service

The service is an approved Nevada Medicaid State Plan service that is not included within an approved FQHC encounter.
The service is provided by a licensed Qualified Health Professional and may be reimbursed on the same date of service as an encounter.
The FQHC is enrolled in the appropriate provider type and meets all MSM coverage guidelines for the specific ancillary service.
An FQHC may have administrative oversight through a contractual agreement with an organization providing outpatient Partial Hospitalization Program (PHP) services that meets Certified Mental Health Clinic criteria; PHP services must follow MSM Chapter 400 policy.

Dually enrolled FQHC/CCBHC

The FQHC and CCBHC maintain internal policies for appropriate treatment placement and determine the appropriate billing model for medically appropriate rendered services.
Clinical medical necessity, clinical appropriateness, and care coordination are considered when services overlap the FQHC and CCBHC scopes of service.
Services primarily CCBHC and not exclusively FQHC-specific are billed at the CCBHC PPS rate; services primarily FQHC-specific and not exclusively CCBHC are billed at the FQHC encounter rate.
Care coordination prevents duplicative billing for the same service occurring at the same time, and Medicaid SUR may conduct retrospective review for duplication.

One encounter for each reimbursable service type

Daily Encounter Limit

Established SSPPS ratesThree

Daily reimbursement limitUp to 3 reimbursable encounters per patient per day

Billing basisOne encounter for each reimbursable service type

Family-Planning Education

Additional reimbursementAvailable for family-planning education

Maximum frequencyUp to 2 times per calendar year

Date requirementMust be billed on the same date of service as the encounter

Emergency Denture Reline

Emergency denture relineMaximum of 1

Prior authorizationNot required for relines

Payment contextDentures provided by an FQHC are included in the daily encounter rate

Denture Adjustments

Maximum adjustments6 dental encounters

FrequencyNo more often than every 6 months

Start of adjustment periodBeginning 6 months after the date of partial/denture purchase

Billing Rule

Family-Planning Education Billing Limit

An FQHC may bill additional reimbursement for family-planning education provided on the same date of service as the encounter, but the additional billing is limited to two times per calendar year.

Refer to the Billing Guide for Provider Type 17, Specialty 181 for billing information.

Documentation Required

Dental Documentation

Document the medical necessity of dental services in the FQHC’s in-office records. The records must substantially support the medical need for the dental encounter or service.

Dental encounters must be provided within the FQHC’s HRSA-approved scope of practice and the practitioner’s applicable regulatory-board requirements.
Bill dental encounters using the applicable FQHC encounter reimbursement methodology.

Prior Authorization

Denture Reline and Adjustment Requirements

Follow the emergency reline, adjustment, and timing limits for dentures provided by the FQHC. Relines and adjustments required during the first six months after purchase are considered prepaid with the Medicaid dental encounter payment for the prosthetic.

Medicaid pays for a maximum of one emergency denture reline and/or six adjustments.
Adjustments may not occur more often than every six months, beginning six months after the partial or denture purchase.
Prior authorization is not required for relines.
Full-denture and partial-denture relines and adjustments required within the first six months are prepaid and not separately reimbursable.

Billing Rule

Telehealth Encounter Billing

For telehealth involving distant-site ancillary services, an FQHC may bill an encounter instead of an originating-site facility fee. When the originating and distant sites are different encounter sites, each site must bill the applicable service.

The originating encounter site must bill the telehealth originating HCPCS code.
The distant encounter site may bill the encounter code.
Refer to MSM Chapter 3400, Telehealth Services.

Billing Rule

Pharmacy Vaccine Billing

FQHC pharmacies must bill Medicaid through point of sale as Provider Type 28 when pharmacists administer vaccines.

Refer to MSM Chapter 1200, Prescribed Drugs.

Billing Rule

Ancillary-Service Enrollment

For ancillary services that are approved Nevada Medicaid State Plan services but are not included in an approved FQHC encounter, enroll under the appropriate provider type and satisfy all applicable MSM coverage guidelines for the specific service.

Ancillary services may be reimbursed on the same date of service as an encounter when provided by a licensed Qualified Health Professional.
Confirm that the service is an approved Nevada Medicaid State Plan service and is outside the approved FQHC encounter.

Billing Rule

FQHC and CCBHC Billing Coordination

When an FQHC is dually enrolled as a CCBHC, maintain internal policies for appropriate treatment placement and coordinate care to select the medically appropriate billing model. Use clinical medical-necessity and appropriateness determinations to prevent duplicate billing for overlapping services.

Determine whether the FQHC encounter or CCBHC model should be used for reimbursement.
Apply care coordination when services overlap the FQHC and CCBHC scopes of service.
Prevent duplicate billing for the same service occurring at the same time.
Consult the CCBHC billing guide services grid and applicable MSM Chapter 2700 guidance.

Unsupported block type: prior_auth

Prior Authorization

Noncontracted FQHC MCO Requirements

An FQHC that is not contracted with a Managed Care Organization must follow the applicable MCO prior-authorization policy.

Confirm the applicable MCO requirements before providing services subject to MCO authorization rules.

Prior Authorization

Ancillary-Service Authorization

Ancillary services billed outside an FQHC encounter must follow the prior-authorization guidelines applicable to the specific services provided.

The FQHC encounter prior-authorization exception does not apply to services billed outside the encounter.

Billing Rule

Ancillary-Service Enrollment and Coverage

Enroll to bill ancillary services under the appropriate provider type and ensure the services meet Nevada Medicaid service-specific coverage requirements.

Ancillary services must be approved Nevada Medicaid State Plan services.
Services may be reimbursed on the same date of service as an encounter when provided by a licensed Qualified Health Professional.

Billing Rule

FQHC and CCBHC Service Placement

For services that could fall within either the FQHC or CCBHC delivery model, determine the medically appropriate placement, maintain internal placement policies, and coordinate care before billing. The selected model must be supported by medical necessity and clinical appropriateness and must not duplicate billing.

Use the CCBHC services grid and applicable billing guidance to identify services covered under the CCBHC model.
The Medicaid SUR unit may conduct retrospective reviews for duplication between the two delivery models.

Billing Rule

CCBHC Versus FQHC Rate Selection

Select the rate based on the primary nature of the service. Services that are primarily CCBHC and not exclusively FQHC services must be billed at the CCBHC PPS rate, while services primarily specific to the FQHC and not exclusively CCBHC services must be billed at the FQHC encounter rate.

Refer to the CCBHC billing guide services grid for services covered under the CCBHC model.
Refer to MSM Chapter 2700 and Billing Guide Provider Type 17, Specialty 188 for CCBHC policy and billing guidance.

May be reimbursed on the same date of service as an encounter when provided by a licensed Qualified Health Professional

Doula

Provider classificationCertified provider

Approval statusApproved to furnish services included in the FQHC outpatient encounter

Related certified providerDoulas are listed alongside Community Health Workers as certified providers

Federally Qualified Health Center

OrganizationA health center defined by the Health Resources and Services Administration

Services providedComprehensive, culturally competent, quality primary health care services

Communities servedMedically underserved communities and vulnerable populations

Ancillary Services

Authorization basisApproved under the Nevada Medicaid State Plan

Encounter relationshipNot included within an approved FQHC encounter

Provider conditionThe FQHC must enroll within the appropriate provider type and meet all MSM coverage guidelines for the specific ancillary service

Medical Necessity

Applicable standardMedical necessity as defined in MSM Chapter 100, Medicaid Program

Reimbursement requirementAll services provided must be medically necessary to receive reimbursement

ScopeThe standard applies to all services provided for which reimbursement is requested

Partial Hospitalization Program (PHP)

Service typePsychiatric treatment services

RecipientsRecipients with chronic mental illness and/or substance-abuse-related disorders

Level of assistanceCollaborative, intensive assistance normally found in an inpatient setting