Federally Qualified Health Center (FQHC)

Definition of Visit

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Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

Federal

Last updated 09/09/2022

For FQHCs, a visit is either of the following:

Face-to-face …

For FQHCs, a visit is either of the following:

Face-to-face encounter (or, for mental health disorders only, an encounter that meets the requirements under paragraph (b)(3) of this section) between an RHC patient and one of the following:

  • Physician assistant.
  • Nurse practitioner.
  • Certified nurse midwife.
  • Visiting registered professional or licensed practical nurse.
  • Clinical psychologist.
  • Clinical social worker.
  • Qualified transitional care management service.

A face-to-face encounter between a patient and either of the following:

  • A qualified provider of medical nutrition therapy services as defined in part 410, subpart G, of this chapter.
  • A qualified provider of outpatient diabetes self-management training services as defined in part 410, subpart H, of this chapter.

A medical visit is a face-to-face encounter between a RHC or FQHC patient and one of the following:

  • Physician assistant.
  • Nurse practitioner.
  • Certified nurse midwife.
  • Visiting registered professional or licensed practical nurse.

A medical visit for a FQHC patient may be either of the following:

  • Medical nutrition therapy visit.
  • Diabetes outpatient self-management training visit.

Visit – Mental health. A mental health visit is a face-to-face encounter or an encounter furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder, including an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient’s medical record, between an RHC or FQHC patient and one of the following:

  • Clinical psychologist.
  • Clinical social worker.
  • Other RHC or FQHC practitioner, in accordance with paragraph (b)(1) of this section, for mental health services.

SOURCE:  Code of Federal Regulation Title 42, Sec. 405.2463, (Accessed Sept. 2022).

FQHC visits must:

  • Be medically necessary
  • Be face-to-face medical or mental health visits or qualified preventive health visits between the patient and an FQHC practitioner (physician, NP, PA, CNM, CP, or CSW), and the practitioner provides one or more qualified FQHC services
  • In certain limited situations, include a registered nurse (RN) or a licensed practical nurse (LPN) homebound patient visit
  • Under certain conditions, a qualified practitioner offers outpatient DSMT or MNT services when the FQHC meets the relevant program requirements to provide these services

SOURCE: CMS MLN Booklet, Federally Qualified Health Center, Jan. 2021, pg. 6 (Accessed Sept. 2021).

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Alabama

Last updated 11/15/2022

Encounters are face-to-face contacts between a patient and a health …

Encounters are face-to-face contacts between a patient and a health professional for medically necessary services.

Billable encounters are visits for face-to-face contact between a patient and a health professional in order to receive medically necessary services such as lab services, x-ray services (including ultrasound and EKG), dental services, medical services, EPSDT services, family planning services, and prenatal services. Billable encounters are forwarded to Medicaid’s fiscal agent for payment through the proper filing of claims forms. Billable services must be designated by procedure codes from the Physicians Current Procedure Terminology (CPT) or by special procedure codes designated by Medicaid for its own use. Non-billable encounters are visits for face-to-face contact between a patient and health professional for services other than those listed above (i.e., visits to social worker, LPN). Such services include, but are not limited to, weight check only or blood pressure check only. Non-billable encounters cannot be forwarded to Medicaid’s fiscal agent for payment.

SOURCE: AL Medicaid, Ch. 15 Alabama FQHC Manual, Oct. 2022, p. 16-5, (Accessed Nov. 2022).

Encounters are face-to-face contacts between a patient and a health professional for the provision of medically necessary services.

  • Ancillary Encounter – Face-to-face contact between a patient and a health professional for lab or x-ray services only.
  • Dental Encounter – Face-to-face contact between a patient and a health professional for the provision of dental services.
  • Medical Encounter – Face-to-face contact between a patient and a health professional for the provision of medical services (i.e., physician, physician assistant, nurse practitioner).
  • EPSDT, Family Planning, or Prenatal Encounter – Face-to-face contact to receive services within the parameters of the program guidelines.

 SOURCE: Ala. Admin. Code r. 560-X-56-.03, (Accessed Nov. 2022).

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Alaska

Last updated 11/17/2022

“Visit” means the aggregate of face-to-face encounters, occurring on the …

“Visit” means the aggregate of face-to-face encounters, occurring on the same calendar day and at a single location, between the health clinic recipient and one or more rural health clinic professionals; for purposes of this paragraph, “aggregate of face-to-face encounters” does not include

  • multiple face-to-face encounters in which, after the first encounter, the recipient suffers an additional illness or injury requiring additional diagnosis or treatment;
  • a face-to-face encounter for dental or mental health diagnosis or treatment that occurs on the same calendar day and single location as one or more face-to-face encounters for medical diagnosis or treatment; or
  • charity care.

SOURCE: AK Admin Code Title 7, Sec. 145.739 (Accessed Nov. 2022).

“Rural health clinic” has the meaning given in AS 47.32.900; “rural health clinic” includes a community health center and a federally qualified health center under 7 AAC 43.870

SOURCE: AK Admin Code Title 7, Sec. 12.990, (Accessed Nov. 2022).

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Arizona

Last updated 10/19/2022

“FQHC/RHC visit” means: A face-to-face encounter with a licensed AHCCCS …

“FQHC/RHC visit” means: A face-to-face encounter with a licensed AHCCCS registered practitioner during which an AHCCCS-covered ambulatory service is provided when that service is not incident to another service.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10 Addendum: FQHC/RHC, (7/12/21), pg. 1, (Accessed Oct. 2022). 

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Arkansas

Last updated 10/17/2022

An FQHC encounter is a face-to-face contact between a patient …

An FQHC encounter is a face-to-face contact between a patient of the FQHC and a health care professional whose services are covered by the Arkansas Title XIX (Medicaid) State Plan.

For coverage and reimbursement purposes, Arkansas Medicaid distinguishes between “core services” encounters and “other ambulatory services” encounters.

A Federally Qualified Health Center (FQHC) “core service” encounter is a face-to-face contact between a patient of the FQHC and a physician, physician assistant, nurse practitioner, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed mental health counselor, or licensed marriage and family therapist and includes services and supplies incidental to the face-to-face contact.

An FQHC “other ambulatory services” encounter is a face-to-face contact between a patient of the FQHC and a contractor or employee of the FQHC whose services for the patient are covered by the particular Medicaid program (e.g., Dental or Visual Care) in which the FQHC is enrolled to provide the other ambulatory services.  For example: A physician in an FQHC diagnoses a 22-year-old patient’s pregnancy and sends her to the FQHC’s dentist for an oral examination as a precaution against dental problems that may complicate the pregnancy.  Arkansas Medicaid covers medical services in a dentist’s office for Medicaid beneficiaries of all ages.  The dentist’s office visit is an “other ambulatory services” encounter.  It is not incident to the FQHC core service encounter because it is not itself an FQHC core service.

SOURCE:  AR Medicaid Provider Manual. Section II FQHC. Rule 214.000, 100 & 200. Updated Oct. 13, 2003. pg. II-10 & 11, (Accessed Oct. 2022).

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California

Last updated 09/06/2022

An FQHC “visit” means a face-to-face encounter between an FQHC …

An FQHC “visit” means a face-to-face encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. A visit shall also include a face-to-face encounter between an FQHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plan’s definition of an FQHC visit. A visit shall also include a face-to-face encounter between an FQHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist.

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care.

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care.

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care.

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) – effective January 1, 2023. (Accessed Sept. 2022).

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Colorado

Last updated 10/21/2022

For Health First Colorado a billable encounter at an FQHC/RHC …

For Health First Colorado a billable encounter at an FQHC/RHC is an in person or telemedicine face to face visit with a Health First Colorado member. Telemedicine services are limited to the procedure codes identified on the Telemedicine Provider Information web page at the Provider Telemedicine web page. When a Federally Qualified Health Center or a Rural Health Clinic provides care through telemedicine, the claim must include the modifier GT on line(s) identifying the service(s).

SOURCE: CO FQHC & RHC Billing Manual 10/22. (Accessed Oct. 2022).

The visit definition for a FQHC includes interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounters.  Any health benefits provided through interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) must meet the same standard of care as in-person care.

SOURCE: Colorado Adopted Rule 8.700.1. (Accessed Oct. 2022).

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Connecticut

Last updated 08/10/2022

“Encounter” means a face-to-face visit between a client and health …

“Encounter” means a face-to-face visit between a client and health professional or an allied health professional for medically necessary services and includes the client’s visit to the FQHC and all services and supplies incidental to the health professional’s services. Visits with more than one health professional or allied health professional or multiple visits with the same health professional or allied health professional that take place on the same day shall be considered one encounter, except under either of the following circumstances: (A) A client, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment; or (B) A client has different types of encounters (medical, behavioral health and dental) for different diagnoses on the same day;

SOURCE: CT FQHC Provider Manual, p. 4 (Oct. 1, 2020). (Accessed Aug. 2022).

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Delaware

Last updated 08/24/2022

A visit is a face-to-face encounter between a center patient …

A visit is a face-to-face encounter between a center patient and any health professional whose services are reimbursed under the State Plan.

Medical FQHC services shall be billed per “medical encounter”. “Encounter” is defined as a face-to-face visit between a FQHC patient and any health professional whose services are reimbursed under the State Plan for the purpose of diagnosis or treatment. Claims are limited to one all-inclusive “encounter” per day, to include all services received by an eligible recipient on a single day or relevant to the “encounter”. All subsequent services and follow-up care provided by other than a physician, nurse practitioner, or physician’s assistant, ordered as a result of an “encounter” are included in the related “encounter” rate, and are not billed separately.

SOURCE: DE FQHC Policy Manual, 10/1/21, p. 4, 9. (Accessed Aug. 2022).

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District of Columbia

Last updated 09/03/2022

No explicit definition.

The FQHC will receive a separate encounter …

No explicit definition.

The FQHC will receive a separate encounter rate for each type of FQHC service offered: primary care, behavioral health, preventive/diagnostic dental and comprehensive dental. The FQHC will be able to bill for same day encounters and be paid one encounter per day.

SOURCE: FQHC Billing Manual, DC Medicaid 16.1, P. 61. (Aug. 24, 2022). (Accessed Sept. 2022).

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Florida

Last updated 10/26/2022

Encounter: A face-to-face contact between a recipient and a health …

Encounter: A face-to-face contact between a recipient and a health care professional who exercises independent judgment in the provision of health services to the individual recipient. For a health service to be defined as an encounter, the provision of the health service shall be recorded in the recipient’s record and completed on site.

Categorically, encounters are:

  1. An encounter between a physician and a recipient during which medical services are provided for the prevention, diagnosis, treatment, and rehabilitation of illness or injury.
  2. Midlevel practitioner. An encounter between an advanced registered nurse practitioner (ARNP) or a physician’s assistant (PA) and a recipient when the ARNP or PA exercises independent judgement in providing health services
  3. An encounter between a dentist and a recipient for the purpose of prevention, assessment, or treatment of a dental problem, including restoration.
  4. Mental Health. An encounter between a licensed psychologist or licensed clinical social worker and recipient for the diagnosis and treatment of mental illness.

SOURCE: Florida FQHC and RHC Reimbursement Plan. July 1, 2014. (Accessed Oct. 2022).

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Georgia

Last updated 10/22/2022

A FQHC or RHC visit is defined as a medically-necessary, …

A FQHC or RHC visit is defined as a medically-necessary, face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more FQHC or RHC services are rendered. A Wellness Visit (Health Check/EPSDT) or Transitional Care Management (TCM) services can also be considered a FQHC or RHC visit. A FQHC or RHC visit can also be a visit between a home-bound patient and an RN or LPN under certain conditions. See section 960.1 of this chapter for information on visiting nursing services to home-bound patients.

SOURCE:  Georgia Department of Community Health, Division of Medicaid, Federally Qualified Health Center Services and Rural Health Clinic Services, p. 8. (Oct 1, 2022). (Accessed Oct. 2022).

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Hawaii

Last updated 10/29/2022

FQHC encounters are face-to-face contacts between a patient and an …

FQHC encounters are face-to-face contacts between a patient and an FQHC covered professional for preventive and/or medically necessary services and include the FQHC facility costs, and all services, and supplies associated with the FQHC covered professional’s services. FQHC encounters also include services and/or supplies that are commonly furnished in a practitioner’s office, without charge, included in the FQHC’s facility costs, and/or furnished as incidental although an integral part of professional services.

Contacts with one or more health care professionals whether more than one is/are qualified (PPS reimbursable) or a combination of qualified and unqualified (not PPS reimbursable) and multiple contacts with the same qualified health care professional that take place on the same day and at a single location constitute a single encounter. Medicaid will only pay for one encounter per day, except as described in 21.4.1.1.

Billable FQHC encounters are face-to-face contacts between a patient and a FQHC covered professional. They include preventive services and medically necessary services such as lab services, diagnostic services such as EKGs, x-ray services (including ultrasounds), dental services, medical services, EPSDT services, family planning services, and prenatal services. Billable FQHC encounters for recipients in the fee-for-service Medicaid program are submitted to MQD for payment through its Fiscal Agent. Billable encounters for recipients in a QI plan are submitted to the plan in which the patient is enrolled.

Non-billable FQHC encounters are: (1) non-face-to-face contacts between a patient and FQHC covered health care professional; (2) face-to-face contacts between a patient and FQHC covered health care professional for non-FQHC covered services; and (3) face-to-face contacts between a patient and a FQHC non-covered professional such as a physical therapist, dental hygienist, and/or audiologist Health screening services in a clinic or community health fair setting such as weight check only or blood pressure check only are not eligible for FQHC PPS reimbursement.

SOURCE: HI Medicaid Provider Manual (FQHC) (March 2016), p. 9-10. (Accessed Oct. 2022).

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Idaho

Last updated 08/22/2022

Encounters fall into one of two categories depending on the …

Encounters fall into one of two categories depending on the provider. Indian Health Service Clinics (IHS) and Federally Qualified Health Centers (FQHC) provide either dental or medical/mental health encounters. An encounter is defined as a face-to-face contact for the provision of one of these types of services between a participant and one of the following:

  • A physician;
  • A physician assistant;
  • A nurse practitioner;
  • A podiatrist;
  • A chiropractor;
  • A clinical social worker;
  • A clinical psychologist;
  • An other specialized nurse practitioner; or
  • A visiting nurse.

SOURCE: ID Medicaid Provider Handbook: IHS, FQHC, and RHC Services (June 14, 2022)., p. 15.  (Accessed Aug. 2022).

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Illinois

Last updated 11/18/2022

For consideration of payment by the Department, encounter clinic services …

For consideration of payment by the Department, encounter clinic services must be provided by a clinic enrolled in the Department’s Medical Programs. The clinic must fall into one of the clinic categories described below.

  • Federally Qualified Health Center (FQHC) – A health care provider that receives a grant under Section 330 of the Public Health Service Act (Public Law 78-410) (42 USC 1395x(aa)(3)) or has been determined to meet the requirements for receiving such a grant by the Health Resources and Service Administration, U.S. Department of Health and Human Services.

The Department is not to be billed for services if the participant is enrolled in a Managed Care Organization (MCO) or a Managed Care Community Network (MCCN).

A billable encounter is defined as one of the following:

  • Medical face-to-face visit with a physician, physician assistant, or Advance Practice Nurse
  • Behavioral health face-to-face visit with a licensed clinical psychologist, licensed clinical social worker, licensed clinical professional counselor, or licensed marriage and family therapist, as applicable
  • Dental face-to-face visit with a dentist

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Providers of Encounter Clinic Services, Chapter D-200 Policy and Procedures for Encounter Clinic Services, p 5 & 16. (Aug 2016). (Accessed Nov. 2022).

“Encounter Clinic” means a Federally Qualified Health Center, Rural Health Clinic or Encounter Rate Clinic, as defined in 89 Ill. Adm. Code 140.461.

SOURCE: IL Administrative Code 89 140.403 (3). (Accessed Nov. 2022).

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Indiana

Last updated 10/30/2022

A valid FQHC or RHC encounter is defined as a …

A valid FQHC or RHC encounter is defined as a face-to-face visit (either in person or via telehealth) between an IHCP member and a qualifying practitioner (see the Rendering Providers section) at an FQHC, RHC or other qualifying, nonhospital setting.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (Jan 1, 2022, published May 19, 2022), p. 4. (Accessed Nov. 2022).

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Iowa

Last updated 07/20/2022

No reference found.

No reference found.

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Kansas

Last updated 08/24/2022

A covered RHC or FQHC “visit” means a face-to-face encounter …

A covered RHC or FQHC “visit” means a face-to-face encounter between a clinic/center patient and a clinic/center health care professional or practitioner (listed below) during which a covered RHC/FQHC service or dental service is rendered:

  • Physician
  • Physician assistant (PA)
  • Advanced practice registered nurse (APRN)
  • Nurse midwife
  • Dentist (for FQHCs only)
  • Clinical psychologist
  • Clinical social worker
  • Registered nurse (RN), for KBH-EPSDT nursing screen only, bill with modifier TD
  • Visiting nurse (if the conditions listed under “visiting nurse services” are fulfilled)
  • Registered dental hygienist, extended care permit (RDH ECP)

Encounters with more than one health professional, or multiple encounters with the same professional, on the same day constitute a single visit.

Just because a service is covered does not automatically mean it is a billable/covered visit.

If an encounter does not involve one of the above listed practitioners, it is not a covered RHC/FQHC visit and should not be billed.

If an examination of the patient is not performed during a face-to-face encounter, it does not constitute a covered RHC/FQHC visit and should not be billed. For example, a visit for the sole purpose of obtaining or renewing a prescription (need for which was determined previously) without a medical examination of the patient is not a covered encounter.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, FQHC/RHC, 8-3 to 4 (Aug. 2022), (Accessed Aug. 2022).

Visit. A “visit” shall mean face-to-face encounter between a center patient and a center health care professional as defined in K.A.R. 129-5-118. Encounters with more than one health professional or multiple encounters with the same health professional that take place on the same day shall constitute a single visit, except under either of the following circumstances:

  • The patient suffers an illness or injury requiring additional diagnosis or treatment after the first encounter.
  • The patient has a different type of visit on the same day, which may consist of a dental, medical, or mental health visit.

SOURCE: KS Admin. Regulation Sec. 129-5-118a, (Accessed Aug. 2022).

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Kentucky

Last updated 10/31/2022

“Visit” means an encounter:

  • Between a recipient or enrollee and

“Visit” means an encounter:

  • Between a recipient or enrollee and a health care provider during which an FQHC, FQHC look-alike, or RHC service is delivered; and
  • That occurs:
    • In person; or
    • Via telehealth if authorized by 907 KAR 3:170.

SOURCE: KY 907 KAR 1:055 (37). (Accessed Oct. 2022).

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Louisiana

Last updated 11/08/2022

Encounter – A face-to-face visit with a physician, physician assistant, …

Encounter – A face-to-face visit with a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, clinical psychologist, clinical social worker, or any other State plan approved ambulatory provider during which an FQHC core or other ambulatory service is rendered. Multiple medical encounters with more than one health care practitioner or with the same health care practitioner, which take place on the same day at a single location, constitute a single visit, except for cases in which the beneficiary, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment.

SOURCE: LA Dept. of Health and Hospitals, Federally Qualified Health Centers Provider Manual, Chapter 22, Glossary C, pg. 42, (As issued on Mar. 10, 2022) (Accessed Nov. 2022).

Medical (inclusive of DSMT services) encounters are defined as face-to-face visits with a physician, physician assistant, nurse practitioner, certified nurse mid-wife, or visiting nurse during which a FQHC service is rendered. Behavioral health encounters are defined as face-to-face visits with a physician with a psychiatric specialty, nurse practitioner with a psychiatric specialty, clinical nurse specialist with a psychiatric specialty, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed marriage and family therapist, respectively, during which behavioral health service is rendered. A behavioral health specific service must be rendered in order to bill a behavioral health encounter.

A dental encounter is defined as a face-to-face visit with a dentist where dental services are rendered.

SOURCE: LA Dept. of Health and Hospitals, Federally Qualified Health Centers Provider Manual, Chapter 22, Sec. 22.1, pg. 15, (As replaced on Mar. 10, 2022) (Accessed Nov. 2022).

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Maine

Last updated 10/18/2022

FQHC unit of service is a visit that includes a …

FQHC unit of service is a visit that includes a facetoface contact with one or more of the center’s core or ambulatory professional and other qualified staff and, where appropriate, receipt of supplies, treatments, and laboratory services.

SOURCE: MaineCare Benefits Manual, Federally Qualified Health Centers, 10-144 Ch. 101, Sec. 31, pg. 2. (Accessed Oct. 2022).

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Maryland

Last updated 11/22/2022

No explicit reference found.

MD regulations refer to federal law …

No explicit reference found.

MD regulations refer to federal law definitions for FQHCs and RHCs:

  • “Federally qualified health center (FQHC)” means an entity as defined by Health-General Article, §24-1301, Annotated Code of Maryland, and §1905(l)(2)(B) of the Social Security Act
  • “Rural health clinic” means a facility that meets the definition of a rural health clinic as contained in 42 CFR §491.2(f).

SOURCE: COMAR 10.09.03.01 & COMAR 10.09.08.01. (Accessed Nov. 2022).

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Massachusetts

Last updated 11/18/2022

Home Visit — a face-to-face meeting between a member and …

Home Visit — a face-to-face meeting between a member and a physician, physician assistant, certified nurse practitioner, clinical nurse specialist, or registered nurse in the member’s residence for examination, diagnosis, or treatment.

Hospital Visit — a face-to-face meeting between a member and a physician, physician assistant, certified nurse practitioner, clinical nurse specialist, or registered nurse when the member has been admitted to a hospital by a physician on the CHC’s staff.

Individual Medical Visit — a face-to-face meeting at the CHC between a member and a physician, physician assistant, certified nurse practitioner, clinical nurse specialist, or registered nurse for medical examination, diagnosis, or treatment.

Individual Mental Health Visit —a face-to-face meeting at the CHC between a patient and either a psychiatrist or an advanced practice registered nurse (APRN) with a graduate degree and advanced training in psychiatric care (a psychiatric clinical nurse specialist or a psychiatric mental health nurse practitioner) within the community health center setting, for purposes of examination, diagnosis, or treatment.

SOURCE: MA 130 CMR 405.402, (Accessed Nov. 2022).

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Michigan

Last updated 11/22/2022

An allowable FQHC encounter means a face-to-face medical visit between …

An allowable FQHC encounter means a face-to-face medical visit between a patient and the provider of health care services who exercises independent judgment in the provision of health care services. Encounters may be classified as medical, dental, or behavioral health.

An encounter occurs between a medical provider and a patient when medical services are provided for the prevention, diagnosis, treatment, or rehabilitation of an illness or injury. Included in this category are physician visits and mid-level practitioner visits. Family planning medical visits are a subset of medical visits.

SOURCE: Dept. of Health and Human Services Medicaid Provider Manual, p. 740, Oct. 1, 2022 (Accessed Nov. 2022). 

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Minnesota

Last updated 10/24/2022

Medical encounter: Services provided during a medical visit, including but …

Medical encounter: Services provided during a medical visit, including but not limited to the following:

  • FQHC or RHC professional services provided to FQHC or RHC patients if covering inpatient hospital visits
  • FQHC or RHC professional services provided to FQHC or RHC patients if surgical services are directly provided by the center or clinic

SOURCE: MN Department of Human Services, Federally Qualified Health Center and Rural Health Center, Revised Jan. 10, 2022. (Accessed Oct. 2022).

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Mississippi

Last updated 11/17/2022

The Division of Medicaid defines a Federally Qualified Health Center …

The Division of Medicaid defines a Federally Qualified Health Center (FQHC) encounter as a face-to-face visit for the provision of services provided by physicians, physician assistants, nurse practitioners, nurse midwives, dentists, optometrists, clinical psychologists, Licensed Clinical Social Workers (LCSWs), Licensed Professional Counselors (LPCs), Licensed Marriage and Family Therapists (LMFTs), and Board-Certified Behavioral Analysts (BCBAs).

SOURCE: MS Admin. Code Title 23, Part 211, Rule. 1.1. (Accessed Nov. 2022).

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Missouri

Last updated 08/19/2022

No reference found

No reference found

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Montana

Last updated 11/01/2022

“Visit” has the meaning set forth in ARM 37.86.4402.

SOURCE: …

“Visit” has the meaning set forth in ARM 37.86.4402.

SOURCE: Administrative Rules of Montana 37.86.4401, (Accessed Oct. 2022).

A visit is a face-to-face encounter between an RHC or FQHC patient and an RHC or FQHC health professional for the purpose of providing RHC or FQHC services.

SOURCE: Administrative Rules of Montana 37.86.4402, (Accessed Oct. 2022).

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Nebraska

Last updated 11/18/2022

Encounter means a face-to-face visit between a Medicaid-eligible patient and …

Encounter means a face-to-face visit between a Medicaid-eligible patient and a physician, physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner, visiting nurse, clinical psychologist, or clinical social worker during which an FQHC service is rendered. Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and at a single location constitute a single visit, except for cases in which the patient, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment.

SOURCE:  NE Admin. Code Title 471, Sec. 29-003.01, Ch. 29, Manual Letter #11-2010. (Accessed Nov. 2022).  

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Nevada

Last updated 11/03/2022

A face-to-face “visit” or an “encounter” between a patient and …

A face-to-face “visit” or an “encounter” between a patient and one or more approved licensed Qualified Health Professional and/or certified provider that takes place on the same day with the same patient for the same service type; this includes multiple contacts with the same provider.

SOURCE: Federally Qualified Health Center Manual, Chapter 2900 (pg. 1), (Accessed Nov. 2022).

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New Hampshire

Last updated 11/10/2022

An encounter is comprised of all recipient visits with more …

An encounter is comprised of all recipient visits with more than one health care practitioner or multiple visits with the same health care practitioner which take place on the same day and at a single location, for the same diagnosis or treatment. A recipient may have one medical and one behavioral encounter on the same day. Providers may submit only one medical encounter and one behavioral health encounter per date of service unless a service authorization has been approved for two specific exceptions as follows:

  • Subsequent to the first encounter, the recipient suffers an illness or injury with a different diagnosis; or
  • Subsequent to the first encounter, the patient received a different treatment at a different time of the same day

SOURCE: NH Medicaid FQHC, FQHC-LAL, 7 RHC (NHB) Manual Jan. 2018, (Accessed Nov. 2022).

“Visit” means a face-to-face encounter which takes place on a single day, at a single location, between a recipient and a health professional in a rural health clinic or FQHC.

SOURCE: Administrative Rules Part HeW 537.01 Rural Health Clinics/ Federally Qualified Health Centers, (Accessed Nov. 2022).

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New Jersey

Last updated 09/06/2022

A medical encounter is a face-to-face contact between a beneficiary …

A medical encounter is a face-to-face contact between a beneficiary and a physician or other licensed practitioner acting within his or her respective scope of practice, including a podiatrist, optometrist, chiropractor, advanced practice nurse, or nurse midwife.

SOURCE: NJ Administrative Code 10:66-4.1, (Accessed Sept. 2022).

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New Mexico

Last updated 10/28/2022

A visit is a face-to-face encounter between a center client …

A visit is a face-to-face encounter between a center client and a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, qualified clinical psychologist or qualified clinical social worker.

Encounters with more than one health professional and multiple encounters with the same health professional on the same day and at a single location constitute a single visit, except when one of the following conditions exist:

  • After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment;
  • The client has a dental visit, or medical visit and another health visit (e.g., a face-to-face encounter between the client and a clinical psychologist, clinical social worker, or other health professional for mental health services listed in Subsection C of 8.310.4.12 NMAC

SOURCE: NM Administrative Code 8.310.4.15. (Accessed Oct. 2022).

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New York

Last updated 08/25/2022

For Medicaid patients, the basis of payment for most clinic …

For Medicaid patients, the basis of payment for most clinic services provided in hospital outpatient departments and diagnostic and treatment centers under Article 28 of the Public Health Law is the threshold visit. New York State Department of Health (DOH) regulation at 10 NYCRR 86-4.9 states: “A threshold visit occurs each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit.”

Qualified Threshold Visit: A qualifying threshold visit is one where the registered clinic patient has an encounter with a physician, physician assistant, nurse practitioner or licensed midwife for services that include comprehensive primary care.

SOURCE: NY Medicaid Policy Manual for Article 28 Certified Clinics, June 1, 2007, p. 3, 40. (Accessed Aug. 2022).

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North Carolina

Last updated 11/03/2022

A core visit shall be a professional service that is …

A core visit shall be a professional service that is rendered during a face-to-face encounter by a physician or other health professional listed in this policy. If the only services rendered during a visit are “incident to” services ordinarily performed by a nurse, technician, or office assistant (such as taking blood pressure and temperature, giving injections, or changing dressings), the visit does not constitute a core visit.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 8-9, Dec. 1, 2020. (Accessed Nov. 2022).

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North Dakota

Last updated 11/08/2022

For FQHCs, the term “encounter” is defined as a face-to-face …

For FQHCs, the term “encounter” is defined as a face-to-face visit with the member during which a qualifying encounter service is rendered. FQHCs may furnish services that qualify as a medical, dental or behavior health encounter.

SOURCE: ND Medicaid General Information Provider Manual, Oct. 2022, pg. 49, (Accessed Nov. 2022). 

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Ohio

Last updated 09/07/2022

For PPS services other than transportation, a visit is one …

For PPS services other than transportation, a visit is one face-to-face (person-to-person) encounter between a patient and a provider; for Medicaid payment purposes, a covered service rendered through telehealth by an FQHC or RHC practitioner is a face-to-face encounter. For transportation services, a visit is a one-way trip provided to or from a site where a covered service is rendered on the same date.

A visit may be conducted through telehealth if the service is rendered in accordance with rule 5160-1-18 of the Administrative Code.

SOURCE: OH Administrative Code 5160-28-01. (Accessed Sept. 2022).

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Oklahoma

Last updated 09/05/2022

“Encounter” or “visit” means a face-to-face contact between an approved …

“Encounter” or “visit” means a face-to-face contact between an approved health care professional as authorized in the FQHC pages of the Oklahoma Medicaid State Plan and an eligible SoonerCare member for the provision of defined services through a Health Center within a twenty-four (24) hour period ending at midnight, as documented in the patient’s medical record.

SOURCE: OK Admin. Rule 317:30-5-659. (Accessed Sept. 2022).

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Oregon

Last updated 11/10/2022

For the provision of services defined in Titles XIX and …

For the provision of services defined in Titles XIX and XXI and provided through an FQHC or RHC, an “encounter” is defined as a face-to-face or telephone contact between a health care professional and an eligible OHP client within a 24-hour period ending at midnight, as documented in the client’s medical record. See rule for limitations for telephone contacts that qualify as encounters. For purposes of this rule, a face-to-face “encounter” includes services provided via a synchronous two-way audiovisual link between a patient and a provider per OAR 410-130-0610.

Telephone encounters qualify as a valid encounter for services provided in accordance with OAR 410-130-0595, Maternity Case Management (MCM) and 410-130-0190, Tobacco Cessation (see also OAR 410-120-1200). Except as set forth below, providers may not make telephone contacts at the exclusion of face-to-face visits. Telephone encounters must include all the same components of the service as if provided face-to-face.

SOURCE: OR OAR 410-147-0120, Healthy Systems Division: Medical Assistance Programs, Federally Qualified Health Center and Rural Health Clinics Services.  (Accessed Nov. 2022).

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Pennsylvania

Last updated 09/06/2022

An encounter is a face-to-face contact between a patient and …

An encounter is a face-to-face contact between a patient and the physician, dentist or mid-level practitioner who exercises independent judgment in the provision of health care services. Claims for encounters are prepared and submitted for payment according to the billing instructions outlined in the PA PROMISeTM Provider Handbook for the 837 Professional/CMS-1500 Claim Form. For a health service to be defined as an encounter, the provision of the health services must be recorded in the patient’s record.

See Appendix for complete list of qualifying encounters.

SOURCE: PA PROMISe Provider Handbook, Appendix E, FQHC/RHC (Accessed Sept. 2022).

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Puerto Rico

Last updated 09/08/2022

No reference found.

No reference found.

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Rhode Island

Last updated 10/21/2022

No Reference found

No Reference found

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South Carolina

Last updated 08/12/2022

Currently the definition of a visit is a face-to-face encounter …

Currently the definition of a visit is a face-to-face encounter between an FQHC patient and a physician, PA, NP, CNM, chiropractor, clinical psychologist or clinical social worker, during which a Medicaid-covered FQHC core service is furnished. The South Carolina Medicaid program does not cover nutrition, health education, social work, or other related ancillary services unless noted in this section. For billing purposes, SCDHHS has deemed a “visit” as an “encounter”. Physicians and practitioners providing services under the FQHC program must meet the regular Medicaid enrollment requirements to provide services to Medicaid patients.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 143 (July 2022). (Accessed Aug. 2022).

A mental health visit is defined as a face-to-face encounter between the FQHC beneficiary and the Physician, Clinical Psychologist, Clinical Social Worker, APRN, Physician Assistant, and Certified Nurse Midwife or an Allied Professional under the direct supervision of a Physician or APRN for mental health services.

SOURCE: SC Health and Human Svcs. Dept. FQHC Behavioral Health Services Provider Manual (July 2019), p. 13. (Accessed Aug. 2022).

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South Dakota

Last updated 11/10/2022

A “visit” is a face-to-face encounter between a FQHC or …

A “visit” is a face-to-face encounter between a FQHC or RHC patient and a provider listed in the Eligible Provider section of this manual that can generate a PPS encounter. Services must be provided under the medical direction of a physician.

“Visit,” a face-to-face or telehealth encounter between a federally qualified health center or rural health clinic patient and a physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, mental health provider listed in ARSD 67:16:41:03, dentist, or an accredited substance use disorder provider.

SOURCE: SD Medicaid Billing and Policy Manual, FQHC and RHC Services, June. 2022, pg. 3 & 11 (Accessed Nov. 2022).

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Tennessee

Last updated 09/04/2022

Visit. A medically-necessary face-to-face medical or mental health encounter or …

Visit. A medically-necessary face-to-face medical or mental health encounter or a qualified preventive health encounter between the patient and a physician, nurse practitioner (NP), physician’s assistant (PA), certified nurse-midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), licensed professional counselor (LPC), or PharmD during which time one (1) or more qualified RHC, FQHC, or FQHCLA Medicaid covered services are furnished. In certain limited situations, an RHC, FQHC, or FQHCLA visit may also include a visit by a registered professional nurse or a licensed practical nurse to a homebound patient. For a provider that has an established Non-Core

Reimbursement Rate, a Non-Core Visit will include a face-to-face encounter with a licensed professional for which the rate was established, during which time one (1) or more qualified Non-Core Visit covered services are furnished.

SOURCE: TN State Plan Under Title XIX of the Social Security Act, Attachment 4.19B. (Accessed Sept. 2022).

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Texas

Last updated 09/07/2022

A visit is a face-to-face, telemedicine, or telehealth encounter between …

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE:  Texas Admin Code Title 1, Sec. 355.8261, (Accessed Sept. 2022).

A visit is a face-to-face encounter between an FQHC client and a physician, PA, NP, CNM, visiting nurse, qualified clinical psychologist, clinical social worker, other health-care professional for mental health services, dentist, dental hygienist, or optometrist. Encounters that take place on the same day at a single location with more than one health-care professional or multiple encounters with the same health-care professional constitute a single visit, except where one of the following conditions exists:

    • After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment.
    • The FQHC client has a medical visit and an other health visit such as a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a THSteps medical checkup.

All services provided that are incidental to the encounter, including developmental screening, must be included in the total charge for the encounter. They are not billable as a separate encounter.

SOURCE: Tx Medicaid Clinics and other Outpatient Facility Services Handbook, pg. 13, (Sept. 2022). (Accessed Sept. 2022).

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Utah

Last updated 08/23/2022

FQHC Provider manual refers providers to Federal Law (Title 42, …

FQHC Provider manual refers providers to Federal Law (Title 42, Subpart X) for definitions specific to FQHCs.

SOURCE: UT Division of Medicaid and Health Financing. Utah Medicaid Provider Manual, Rural Health Clinics and Federally Qualified Health Centers Services, Oct. 2021, pg. 3, (Accessed Aug. 2022).

For FQHCs, a visit is either of the following:

  • A visit as described in paragraph (a)(1)(i) or (ii) of this section.
  • A face-to-face encounter between a patient and either of the following:
    • A qualified provider of medical nutrition therapy services as defined in part 410, subpart G, of this chapter.
    • A qualified provider of outpatient diabetes self-management training services as defined in part 410, subpart H, of this chapter.

A medical visit is a face-to-face encounter between a RHC or FQHC patient and one of the following:

  • Physician.
  • Physician assistant.
  • Nurse practitioner.
  • Certified nurse midwife.
  • Visiting registered professional or licensed practical nurse.

A medical visit for a FQHC patient may be either of the following:

  • Medical nutrition therapy visit.
  • Diabetes outpatient self-management training visit.

A mental health visit is a face-to-face encounter or an encounter furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder, including an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient’s medical record, between an RHC or FQHC patient and one of the following:

  • Clinical psychologist.
  • Clinical social worker.
  • Other RHC or FQHC practitioner, in accordance with paragraph (b)(1) of this section, for mental health services.

SOURCE:  Code of Federal Regulation, Title 42, Part 405, Sec. 2463, (Accessed Jun. 2022).

Diabetes self-management training (DSMT).

  • FQHCs – Offer DSMT services. A face-to-face encounter is required and must be provided as part of an encounter to qualify for coverage.

SOURCE: UT Division of Medicaid and Health Financing. Utah Medicaid Provider Manual, Rural Health Clinics and Federally Qualified Health Centers Services, Oct. 2021, pg. 4, (Accessed Aug. 2022).

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Vermont

Last updated 10/27/2022

An Encounter at a FQHC/RHC is defined as a face-to-face …

An Encounter at a FQHC/RHC is defined as a face-to-face visit between a member and a provider. Face-to-face visits with more than one provider and multiple visits with the same provider that take place on the same day and the same location constitute a single visit, except when one of the following conditions exists

  • After the first encounter, the member suffers illness or injury requiring additional diagnosis or treatment
  • The patient has a medical visit with a physician, physician assistant, nurse practitioner, nurse midwife, or a visiting nurse, and a visit with a clinical psychologist, clinical social worker, or other health professional for mental health services. Vermont Medicaid follows the same list of health professionals as Medicare.

A Vermont Medicaid encounter does not include total OB care.

SOURCE: Vermont Medicaid Federally Qualified Health Centers (FQHC)/Rural Health Clinics (RHC) Supplement (Jan. 2022), (Accessed Oct. 2022).

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Virgin Islands

Last updated 09/08/2022

No reference found.

No reference found.

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Virginia

Last updated 11/23/2022

No reference found

No reference found

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Washington

Last updated 08/26/2022

Encounter: A face-to-face or telehealth visit between a client and …

Encounter: A face-to-face or telehealth visit between a client and a qualified FQHC provider (e.g., a physician, physician assistant, or advanced registered nurse practitioner) who exercises independent judgment when providing services that qualify for an encounter rate.

All services must be documented in the client’s file to qualify for an encounter.

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 9, 20 (Aug. 2022), (Accessed Aug. 2022).

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West Virginia

Last updated 09/02/2022

A billable encounter is defined as a face-to-face visit between …

A billable encounter is defined as a face-to-face visit between an eligible practitioner and a patient where the practitioner is exercising independent professional judgment consistent within the scope of their license.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual. Chapter 522.8 Federally Qualified Health Center and Rural Health Clinic Svcs. P. 16. (July 1, 2019). (Accessed Sept. 2022).

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Wisconsin

Last updated 11/21/2022

A CHC encounter is defined as a face-to-face visit on …

A CHC encounter is defined as a face-to-face visit on a single DOS between a member and a Medicaid-enrolled CHC provider to provide diagnosis, treatment, or preventive service(s) at the CHC HRSA-approved location including main and off-site locations.

SOURCE: WI ForwardHealth Online Handbook Community Health Center Encounters, (Accessed Nov. 2022).

For currently covered services, services that are considered direct when provided in-person will be considered direct when provided via telehealth.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth & ForwardHealth Update Dec. 2021, No. 2021-50. (Accessed Nov. 2022). 

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Wyoming

Last updated 10/20/2022

A medical visit is a face-to-face encounter between a Member …

A medical visit is a face-to-face encounter between a Member and:

  • Dental Professional (ADA Dental Claim Form)
  • Nurse Practitioner
  • Nurse Midwife
  • Physician
  • Physician’s Assistant
  • Visiting Nurse

Medical visits can also consist of:

  • Medical nutrition therapy
  • Diabetes outpatient self-management training

A dental visit is a face-to-face visit between a Member and a:

  • Dentist
  • Orthodontist

Dental care team specialist supervised by one of the above

  • Other health visits are a face-to-face encounter between a Member and:
  • Clinical Psychologist
  • Clinical Social Worker
  • Other health professional for mental health services

NOTE: When a practitioner is performing services outside the FQHC facility, services cannot be billed under the FQHC NPI number. The services will need to be billed under the practitioner’s NPI on a professional/837P claim. 

SOURCE: WY Dept. of Health, Medicaid Institutional Provider Manual, pgs. 238-239, (Sept. 30, 2022). (Accessed Oct. 2022).

 

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Federally Qualified Health Center (FQHC)

Definition of Visit

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