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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 7 Rural Health Clinic : 7.2 Services, Benefits, Limitations, and Prior Authorization

7.2
7.2.1
General services and copayments are billed using the RHC’s National Provider Identifier (NPI). All other services billed using the RHC’s NPI are processed as informational only.
Important:
If an RHC facility provider submits a claim for THSteps and Family Planning services, the services will process as informational only and will not be reimbursed.
The following services are benefits of Texas Medicaid when provided in an RHC:
Visiting nurse services on a part-time or intermittent basis to homebound clients in areas determined to have a shortage of home health agencies (A homebound client is someone who is permanently or temporarily confined to his place of residence, not including a hospital or skilled nursing facility (SNF), because of a medical condition.)
When an RHC bills for visiting nurse services, the written plan of treatment to be used for the visiting nurse must be developed by the RHC supervising physician. It must be approved and ordered by the client’s treating physician if different from the supervising physician. The plan of treatment must be reviewed and approved by the supervising physician of the clinic at least every 60 days.
A visit is a face-to-face encounter between an RHC client and a physician, PA, NP, CNM, visiting nurse, or clinical NP. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one or the other of the following conditions exists:
An other health visit includes, but is not limited to, a face-to-face encounter between an RHC client and a clinical social worker.
For freestanding RHCs, all laboratory services provided in the RHC’s laboratory are included in the encounter. This includes the basic laboratory tests as well as any other laboratory tests provided in the RHC laboratory. Consequently, there is no separate billing for laboratory services. However, if the RHC laboratory becomes a certified Medicare laboratory with its own supplier number, and enrolls in Medicaid as an independent laboratory, all laboratory tests (except the basic laboratory tests) performed for RHC and non-RHC clients can be billed to Medicaid. The claim must be filed under their independent laboratory Medicaid provider identifier and using the appropriate HCPCS codes.
Refer to:
The Medicare website at www.cms.gov for more information about Medicare RHC laboratory requirements.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.