ModifiedNevada Health AuthorityPolicy N/A

Federally Qualified Health Center Medicaid Reimbursement

Customize your policy alerts

Sign up for all Nevada Health Authority policy alerts

Know when Nevada Health Authority releases new policies or updates existing guidance.

Monitor payer policy activity

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

This chapter governs Nevada Medicaid reimbursement, coverage, encounter billing, non-covered services, ancillary services, and related requirements for Federally Qualified Health Centers and approved practitioners, including medical, behavioral health, dental, pharmacy, and telehealth services.

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Center Medicaid Reimbursement

Policy CodePolicy N/A

Change TypeModified

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionBill no more than one reimbursable encounter per patient per day for each established SSPPS service type.

SourceLink

POLICY UPDATE CHANGES

Licensed Pharmacists were added as an approved provider type for FQHC encounters.

Licensed Marriage and Family Therapists were added to the behavioral health encounter rate.

The chapter was reorganized and renumbered, with language and section arrangements revised for clarity.

Nevada statutory authority references were expanded to include pharmacy and marriage and family therapy statutes.

2Substantive provider additions

3FQHC encounter service categories

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedNevada Health AuthorityPolicy N/A

Federally Qualified Health Center Medicaid Reimbursement

Customize your policy alerts

Sign up for all Nevada Health Authority policy alerts

Know when Nevada Health Authority releases new policies or updates existing guidance.

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 Center Medicaid Reimbursement

Policy CodePolicy N/A

Change TypeModified

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionBill no more than one reimbursable encounter per patient per day for each established SSPPS service type.

SourceLink

POLICY UPDATE CHANGES

Licensed Pharmacists were added as an approved provider type for FQHC encounters.

Licensed Marriage and Family Therapists were added to the behavioral health encounter rate.

The chapter was reorganized and renumbered, with language and section arrangements revised for clarity.

Nevada statutory authority references were expanded to include pharmacy and marriage and family therapy statutes.

2Substantive provider additions

3FQHC encounter service categories

1-3Maximum daily encounters

5Non-covered service categories

No PAFQHC encounter prior authorization

100%Medical necessity requirement

FQHC Encounter Coverage and Reimbursement

General FQHC encounter coverage

An FQHC encounter is reimbursable when all of the following are met:

ALL of the following

ALL of the following
- Service is medically necessary.
- Encounter includes preventive and/or primary health services.
- Encounter is categorized as medical, mental/behavioral health, or dental.
- 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 scope of practice.
Daily encounter billing does not exceed the applicable limit: one encounter per patient per day with one established SSPPS rate, up to two with two established SSPPS rates, or up to three with three established SSPPS rates.1–3 encounters per patient per day, depending on established SSPPS rates

Medical encounter coverage

Medical encounter coverage requires an eligible provider and includes any of the following services:

ALL of the following

Service is furnished within the FQHC's HRSA-approved scope of services and the practitioner's applicable state regulatory board scope of practice.
ONE or more of
- Primary care services, including medical history, physical examination, assessment of health status, treatment of conditions amenable to ambulatory medical management, and related supplies.
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening consistent with applicable periodicity recommendations.
- Preventive health services and education recommended with a Grade A or B by the United States Preventive Services Task Force (USPSTF).

Behavioral and mental health encounter coverage

Behavioral and mental health encounter coverage requires an eligible provider and a covered behavioral health, substance use, or co-occurring disorder service:

ALL of the following

Service is furnished by an employed or contracted Psychiatrist, Psychologist, APRN, PA, LMFT, or LCSW authorized by the FQHC and permitted under the practitioner's applicable state scope of practice.
ONE or more of
- Screening, assessment, diagnosis, or treatment of behavioral/mental health conditions, substance use disorders, or co-occurring disorders.
- Clinically appropriate evidence-based therapy, counseling, or medication management for behavioral/mental health conditions, substance use disorders, or co-occurring disorders.

Dental encounter coverage

Dental encounter coverage requires all of the following:

ALL of the following

Dental service is furnished by an employed or contracted Dentist or Registered Dental Hygienist (RDH) within the FQHC's HRSA-approved scope and the practitioner's applicable regulatory board scope of practice.
The FQHC's in-office records substantially document the medical need for the dental service.
Applicable denture requirement is met
- Emergency denture reline is limited to a maximum of one and is performed no more often than every six months beginning six months after the date of partial or denture purchase.Maximum 1 reline; not more often than every 6 months beginning 6 months after purchase
- Denture adjustment is limited to a maximum of six dental encounters and is performed no more often than every six months beginning six months after the date of partial or denture purchase.

Non-covered FQHC encounter services

The service is not reimbursable under an FQHC encounter if it is any of the following:

ALL of the following

Service is not group therapy.
Service is not eyeglasses.
Service is not hearing aids.
Service is not durable medical equipment, prosthetics, orthotics, or supplies.
Service is not ambulance services.

Medical necessity requirement

All services must meet the following requirement to receive reimbursement:

ALL of the following

Service is medically necessary as defined in MSM Chapter 100 — Medicaid Program.

Ancillary service reimbursement

Ancillary service reimbursement is available when all of the following are met:

ALL of the following

Service is an approved Nevada Medicaid State Plan service.
Service is not included within an approved FQHC encounter.
The FQHC is enrolled in the appropriate provider type.
All MSM coverage guidelines for the specific ancillary service are met.
When provided on the same date of service as an FQHC encounter, the ancillary service is furnished by a licensed Qualified Health Professional.

Dual FQHC/CCBHC billing

For an FQHC dually enrolled as a CCBHC, reimbursement requires all of the following:

ALL of the following

Medical necessity and clinical appropriateness are established by the clinical professionals under care coordination.
The service is assigned to the appropriate delivery model under the FQHC's and CCBHC's internal policies.
Select the applicable reimbursement model
- Use the CCBHC PPS rate when the service is primarily CCBHC and is not an exclusively FQHC service.
- Use the FQHC encounter rate when the service is primarily FQHC-specific and is not an exclusively CCBHC service.

Billing Codes and Encounter Limits

Telehealth billing codeHCPCS

Telehealth originating HCPCS code billed by the originating encounter site

Provider Type 28 point-of-sale billing for pharmacist-administered vaccinesmixedCovered

Provider Type 28

FQHC pharmacies billing Medicaid for vaccines administered by pharmacists must bill through point of sale as Provider Type 28.

Provider types and specialties identified in the changemixedCovered

PT 17	FQHC
specialty 181	FQHC specialty
PT 91	Licensed Pharmacist
PT 14	Licensed Marriage and Family Therapist
specialty 306	Licensed Marriage and Family Therapist specialty

Daily encounter limit

Established SSPPS ratesOne

Reimbursable encounters1 encounter per patient per day

Billing conditionThe encounter must be for an established service type

Daily encounter limit

Established SSPPS ratesTwo

Reimbursable encountersUp to 2 encounters per patient per day

Billing condition

Provider Billing and Documentation Responsibilities

Billing Rule

Encounter Frequency Limits

Bill no more than one reimbursable encounter per patient per day for each established Service Specific Prospective Payment System (SSPPS) service type. The daily limit depends on the number of established SSPPS encounter rates.

One SSPPS rate: maximum one reimbursable encounter per patient per day.
Two SSPPS rates: maximum two reimbursable encounters per patient per day.
Three SSPPS rates: maximum three reimbursable encounters per patient per day.
Service types are medical, mental/behavioral health, and dental; multiple contacts with the same provider on the same day for the same service type constitute one encounter.

Billing Rule

Medical Encounter Provider Eligibility

Ensure medical encounters are provided by an employed or contracted practitioner whose services fall within the FQHC’s HRSA-approved scope of services and the practitioner’s applicable state regulatory board scope of practice.

Key Terms

Definitions

TermFederally Qualified Health Center (FQHC)

Primary care standardProvides comprehensive, culturally competent, quality primary health care services

Communities servedMedically underserved communities and vulnerable populations

Definitions

TermEncounter

Visit typeA face-to-face visit or encounter between a patient and one or more approved licensed Qualified Health Professionals and/or certified providers

Same-day requirement

Policy Summary

PayerNevada Health Authority

PolicyFederally Qualified Health Center Medicaid Reimbursement

Policy CodePolicy N/A

Change TypeModified

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionBill no more than one reimbursable encounter per patient per day for each established SSPPS service type.

SourceLink

On This Page

Family planning services, including contraceptives.

Women's preventive gynecological examination, clinical breast examination, thyroid function testing, and maternity care, including antepartum, labor and delivery, and postpartum care.

Vision and hearing screening.

Community Health Worker services or doula services.

Maximum 6 adjustments; not more often than every 6 months beginning 6 months after purchase

A full denture or partial reline or adjustment required within the first six months is treated as prepaid with the Medicaid dental encounter payment for the prosthetic.

Care is coordinated to prevent duplicate billing for the same service occurring at the same time.

Each reimbursable service type may be billed once per patient per day

Daily encounter limit

Established SSPPS ratesThree

Reimbursable encountersUp to 3 encounters per patient per day

Billing conditionEach reimbursable service type may be billed once per patient per day

Family planning education billing

ServiceFamily planning education

Additional reimbursementsUp to 2 per calendar year

Date requirementThe additional reimbursements must be on the same date of service as the encounter

Emergency denture relines

ServiceEmergency denture reline

Maximum payable1 emergency denture reline

Timing limitNot more often than every 6 months, beginning 6 months after the date of partial or denture purchase

Denture adjustments

ServiceDenture adjustments

Maximum payable6 dental encounters

Timing limitNot more often than every 6 months, beginning 6 months after the date of partial or denture purchase

Eligible practitioners include physicians or osteopaths, APRNs, PAs, nurse midwives, CRNAs, podiatrists, optometrists, opticians, licensed pharmacists, CHWs, doulas, and RDs.
Bill the encounter under the applicable FQHC encounter reimbursement methodology.

Billing Rule

Behavioral Health Provider Eligibility

Use employed or contracted behavioral or mental health practitioners who are authorized to provide the service by the FQHC under its HRSA-approved scope of services and under the practitioner’s applicable state regulatory board scope of practice.

Eligible practitioners include psychiatrists, psychologists, APRNs, PAs, LMFTs, and LCSWs.
Covered services may address behavioral or mental health conditions and substance use disorders, including co-occurring disorders, and may include screening, assessment, diagnosis, treatment, therapy, counseling, and medication management.
Refer to MSM Chapter 400 for mental health and alcohol/substance abuse service requirements.

Documentation Required

Dental Documentation and Denture Reline Rules

Bill dental encounters through the FQHC encounter methodology and retain in-office records that substantially document medical need. Apply the specific limits and authorization rules for emergency denture relines and adjustments.

Dental encounters must be provided by employed or contracted dentists or RDHs under the FQHC’s HRSA-approved scope and the practitioner’s applicable regulatory-board scope of practice.
Medicaid covers a maximum of one emergency denture reline and/or six adjustments, no more often than every six months beginning six months after the partial or denture purchase date.
Prior authorization is not required for relines.
Relines and adjustments required within the first six months are prepaid through the Medicaid dental encounter payment for the prosthetic.
Refer to MSM Chapter 1000 for other covered and non-covered dental services.

Billing Rule

Telehealth Site Billing

For applicable ancillary-service distant-site telehealth encounters, the originating encounter site must bill the telehealth originating HCPCS code when the FQHC bills an encounter in lieu of an originating-site facility fee. The distant encounter site may bill the encounter code.

This applies when the distant site provides ancillary services, such as a specialist consultation.
When the originating and distant sites are different encounter sites, assign billing accordingly and follow MSM Chapter 3400, Telehealth Services.

Unsupported block type: billing_rule

Billing Rule

Ancillary-Service Enrollment

For ancillary services that are approved Nevada Medicaid State Plan services but are not included within an approved FQHC encounter, enroll under the appropriate provider type and meet all 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.
Apply service-specific requirements, including those for Partial Hospitalization Programs when applicable.
Refer to MSM Chapter 400 for PHP policy.

Denial Risk

FQHC and CCBHC Coordination

FQHCs dually enrolled as CCBHCs must establish internal assignment and care-coordination policies to determine the appropriate delivery model for each medically necessary service and prevent duplicate billing.

Consider medical necessity, clinical appropriateness, overlapping scopes of service, and care coordination when selecting the FQHC or CCBHC encounter.
Use the CCBHC services grid and billing guide to identify services covered under the CCBHC model.
The Medicaid SUR unit may retrospectively review billing duplication between the two delivery models.

Prior Authorization

FQHC Encounter Prior Authorization

Do not obtain prior authorization for services billed as FQHC encounters. Retain documentation in the patient file supporting the medical necessity of every service provided.

Prior authorization requirements in other MSM chapters do not apply when the service is performed as an FQHC encounter.

Prior Authorization

Non-Contracted FQHC Prior Authorization

FQHCs that are not contracted with a Managed Care Organization must follow the applicable MCO prior authorization policy.

Prior Authorization

Ancillary Service Authorization

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

Determine authorization requirements under the relevant service policy before billing the ancillary service.

Documentation Required

Medical Necessity Documentation

To receive reimbursement, document and retain support showing that all services provided were medically necessary as defined in MSM Chapter 100, Medicaid Program.

Maintain medical-necessity documentation in the patient file, including for FQHC encounters for which prior authorization is not required.
Ensure documentation supports the service billed and the selected delivery model.

Billing Rule

Ancillary Service Enrollment and Billing

For ancillary services outside an approved FQHC encounter, enroll under the appropriate provider type and comply with the specific MSM coverage guidelines and billing requirements for that service.

Ancillary services may be reimbursed on the same date of service as an encounter when provided by a licensed Qualified Health Professional.
Confirm eligibility, enrollment, coverage, and authorization requirements before billing.

Denial Risk

FQHC and CCBHC Service Coordination

When an FQHC is dually enrolled as a CCBHC, assign each service to the appropriate delivery model, coordinate care, and prevent duplicate billing for overlapping services.

Establish internal policies for placement of treatment and coordination between FQHC and CCBHC services.
Use clinical appropriateness and medical necessity to determine whether the FQHC or CCBHC should request reimbursement.
Monitor claims for duplicate billing for the same service at the same time.

Billing Rule

Dual-Enrollment Rate Selection

Select the prospective payment rate according to the service’s primary delivery model. Services primarily CCBHC and not exclusively FQHC should be billed at the CCBHC PPS rate; services primarily FQHC-specific and not exclusively CCBHC should be billed at the FQHC encounter rate.

Use the CCBHC services grid in the CCBHC billing guide to classify services.
Refer to MSM Chapter 2700 and the CCBHC Billing Guide, Provider Type 17, Specialty 188, for additional guidance.

Takes place on the same day with the same patient for the same service type, including multiple contacts with the same provider

Definitions

TermAncillary service

Service statusAn approved Nevada Medicaid State Plan service

Exclusion from encounterNot included within an approved FQHC encounter

Definitions

TermAncillary services

Service statusApproved Nevada Medicaid State Plan services

Exclusion from encounterNot included within an approved FQHC encounter

Definitions

TermPartial Hospitalization Program (PHP)

Program typeAn outpatient program providing psychiatric treatment modalities

Recipients servedRecipients with chronic mental illness and/or substance abuse-related disorders who require collaborative, intensive assistance normally found in an inpatient setting