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2012 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 4. Federally Qualified Health Center (FQHC) : 4.4 Claims Filing and Reimbursement

4.4 Claims Filing and Reimbursement
4.4.1
All services provided that are incidental to the encounter must be included in the total charge for the encounter and are not billable as a separate encounter. For example, if an office visit was provided at a charge of $30 and a lab test for $15, the center would submit a claim to TMHP for procedure code T1015 for $45 and would be reimbursed at the center’s encounter rate. All services (except for family planning, THSteps medical, THSteps dental, copayments, vision, mental health services, and case management for high-risk pregnant women and infants) provided during an encounter must be submitted for reimbursement using procedure code T1015.
All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendments (CLIA). Providers who do not comply with CLIA are not reimbursed for laboratory services.
Refer to:
Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).
To obtain the encounter rate when submitting claims for family planning services that are provided under Title XIX or WHP, FQHCs must use or the most appropriate E/M procedure code, or procedure code J7300, J7302, or J7307 with a family planning or WHP diagnosis code. Providers must use procedure code J7300, J7302, or J7307 if the visit is for the insertion of a intrauterine device (IUD). These procedure codes must be submitted in conjunction with the most appropriate informational procedure codes for services that were rendered. Providers must use modifier FP only to submit claims for the annual family planning examination.
If a physician of an FQHC provides a service in the hospital (e.g., a delivery), the FQHC can choose to use the physician’s provider identifier to submit claims for that service, if the contract with the physician indicates this occurrence. If the FQHC bills the service using the physician’s provider identifier rather than the FQHC’s provider identifier, the costs that are associated with the service must be excluded from the cost report and will not be considered during the cost settlement/encounter rate setting process.
FQHC services for clients who have only Medicaid must be submitted to TMHP in approved electronic format or on a UB-04 CMS-1450, CMS‑1500, or Family Planning 2017 paper claim form. Providers may purchase UB-04 CMS-1450 or CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a UB-04 CMS-1450 or CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.
The ADA Dental Claim Form can be downloaded at www.ada.org/7119.aspx
The Family Planning 2017 Claim Form can be found in the Forms section of this manual.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Section 6: Claims Filing (Vol. 1, General Information) for general information about claims filing.
Section 12, “Claim Form Examples,” in this handbook.
Claims must be filed as follows:
Family planning claims filed by FQHC providers who have contracted with DSHS
Family planning claims filed by FQHC providers not contracted with DSHS
Case Management for Children and Pregnant Women services
When filing for a client who has Medicare and Medicaid coverage, providers must file on the same claim form that was filed with Medicare.
Services provided by a health-care professional require one of the following modifiers with procedure code T1015, to designate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE, or U7.
If more than one health-care professional is seen during the encounter, the modifier must indicate the primary contact. The primary contact is defined as the health-care professional who spends the greatest amount of time with the client during that encounter.
Use modifier TD or TE for home health services provided in areas with a shortage of home health agencies.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Section 6: Claims Filing (Vol. 1, General Information) for general information about claims filing.
Section 12, “Claim Form Examples,” in this handbook.
Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks)

Texas Medicaid & Healthcare Partnership
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