PPS Rate

In either case, reimbursement for the encounter code (T1015 or D9999) is based on the prospective payment system (PPS) rate specific to the FQHC or RHC facility. All other procedures codes on the claim will deny with EOB 6096 – The CPT/HCPCS code billed is not payable according to the PPS reimbursement methodology.

SOURCE: Indiana Health Coverage Programs, Provider Reference Manual, Telehealth and Virtual Services (Oct. 30, 2024), p. 6.  (Accessed Jul 2025).

The IHCP implemented a prospective payment system (PPS) for reimbursing FQHCs and RHCs for IHCP-covered services.

FQHC and RHC facilities are required to submit fee-for-service claims for valid encounters as follows:

• Report valid medical encounters on the professional claim (CMS-1500 claim form, Portal professional claim or 837P transaction) using HCPCS encounter code T1015 – Clinic, visit/ encounter, all-inclusive.
• Report valid dental encounters on the dental claim (American Dental Association 2012 Dental Claim Form [ADA 2012], IHCP Portal dental claim or 837D transaction) using HCPCS encounter code D9999 – Unspecified adjunctive procedure, by report.  Effective for dates of service on and after July 1, 2021, FQHCs and RHCs are not required to include the T1015 encounter code on crossover claims. See the Crossover Claims for Dually Eligible Members section for details.

Additionally, all claims for valid FQHC and RHC encounters must include one of the following place-of-service (POS) codes:

• 02 – Telehealth*
• 03 – School*
• 04 – Homeless Shelter*
• 11 – Office
• 12 – Home
• 31 – Skilled nursing facility
• 32 – Nursing facility
• 50 – Federally qualified health center
• 72 – Rural health clinic

POS code 10 became allowable for FQHC and RHC encounter claims effective July 21, 2022, and the definition for POS code 02 was changed to specify “other than in a patient’s home.”

FQHC and RHC claims (other than crossover claims) that are submitted with a POS code from the preceding list (02, 03, 04, 10, 11, 12, 31, 32, 50 or 72) and that do not include the T1015 or D9999 encounter code are denied for EOB code 4121 – D9999 & T1015 must be billed with a valid CPT/HCPCS code. Providers can resubmit these claims with the appropriate encounter code properly included on the claim.

When billing valid telehealth encounters, the encounter code (T1015 or D9999) should be billed as usual, and each service provided during the encounter must include an appropriate telehealth POS code (02 or 10) and telehealth modifier (93 or 95), as described in the FQHC and RHC Telehealth Services section of the Telehealth and Virtual Services module.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (May 7, 2024), p. 3-5. (Accessed Jul 2025).