Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)

19.1​Enrollment

Rural health clinics (RHCs), federally qualified health centers (FQHCs), federally qualified look-alikes (FQL), federally qualified satellites (FQS) and rural health clinics can enroll as providers for the Children with Special Health Care Needs (CSHCN) Services Program.

To enroll in the CSHCN Services Program, FQHC and RHC providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the TMHP-CSHCN Services Program enrollment process through the Provider Enrollment and Management System (PEMS), and comply with all applicable state laws and requirements.

Out-of-state FQHC and RHC providers must meet all these conditions and be located in the United States within 50 miles of the Texas state border.

​Important:CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid.

By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 26 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371.

CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 26 TAC §351.6(b)(1).

Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid.

​Refer to: Section 2.1, “Provider Enrollment” in Chapter 2, “Provider Enrollment and Responsibilities” for more detailed information about CSHCN Services Program enrollment procedures.

19.2​Benefits, Limitations and Authorization Requirements

19.2.1​General Medical Services

The procedure codes in the following table are a benefit of the CSHCN Services Program when they are provided by FQHC providers and billed with a general services modifier:

​Note:Procedure codes 96160 and 96161 are benefits of the CSHCN Services Program for clients who are 12 through 18 years of age and are limited to once per calendar year, any provider.

​Refer to: Section 31.2.18.10, “Preventive Care Medical Checkup Components” in Chapter 31, “Physician” in the Physician chapter for more specific information about guidelines and requirements for procedure codes 96160 and 96161.

The general medical services modifiers are defined as follows:

All services provided during an RHC encounter must be submitted using procedure code T1015. The total submitted amount should be the combined charges for all services provided during that encounter.

One of the following modifiers must be reported with procedure code T1015 to designate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE, or U7.

19.2.2​Preventive Care Medical Checkups

The procedure codes in the following table are a benefit of the CSHCN Services Program when they are provided by FQHC providers and billed with one of the general services modifiers above:

​Note:Procedure codes 96160 and 96161 are benefits of the CSHCN Services Program for clients who are 12 through 18 years of age and are limited to once per calendar year, any provider.

​Refer to: Section 31.2.18.10, “Preventive Care Medical Checkup Components” in Chapter 31, “Physician” in the Physician chapter for more specific information about guidelines and requirements for procedure codes 96160 and 96161.

Adult preventive care must be billed with diagnosis code Z0000 or Z0001. Pediatric preventive care must be billed with diagnosis code Z00121 or Z00129. The provider cannot submit modifier EP for pediatric services.

19.2.3​Telecommunication Services

The procedure codes in the following table are a benefit of the CSHCN Services Program when they are provided by FQHC providers for telemedicine services at a distant site location:

​Refer to: Section 38.2.2, “Telemedicine Services” in Chapter 38, “Telecommunication Services” for more detailed information about telemedicine services.

19.2.4​Behavioral Health Services

The procedure codes in the following table are a benefit of the CSHCN Services Program when they are provided by FQHC or RHC providers are billed with a general services modifier:

Mental health services must be billed using one of the appropriate general services modifiers as listed and defined below:

19.2.5​Dental Services

The procedure codes in the following table are a benefit of the CSHCN Services Program when they are provided by FQHC or RHC providers:

Procedure codes D8210, D8220, and D8080 must be billed with the appropriate Diagnostic Procedure Code (DPC) remarks codes for correct claims processing:

19.2.6​ Vision Services

The procedure codes in the following table are a benefit of the CSHCN Services Program when they are provided by FQHC or RHC providers:

19.3​Claims Filing

All services require documentation to support the medical necessity of the service rendered. All services provided are subject to retrospective review and recoupment if documentation does not support the service that was submitted for reimbursement.

FQHC and RHC services must be submitted to TMHP in an approved electronic format or on the following paper claim forms:

For FQHC:

For RHC:

When completing a paper claim form, the provider must include all required information on the claim because information is not keyed from attachments. Super bills or itemized statements are not accepted as claim supplements.

19.4​Reimbursement

CSHCN FQHCs are reimbursed the lower of the billed amount or the Texas Medicaid provider-specific prospective payment system encounter rates.

CSHCN freestanding and hospital-based RHCs are reimbursed the lower of the billed amount or the Texas Medicaid provider-specific per visit rates.

19.5​TMHP-CSHCN Services Program Contact Center

The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.