Federally Qualified Health Center (FQHC)

PPS Rate

Click the map to scroll down to the state
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

Mental Health Visits via Telecommunications

FQHCs and RHCs will be …

Mental Health Visits via Telecommunications

FQHCs and RHCs will be able to furnish mental health visits to include visits furnished using interactive, real-time telecommunications technology and will RHCs and FQHCs can report and be paid for furnishing those visits in the same way they currently do when these services are furnished in-person.  RHCs and FQHCs will be paid for mental health visits furnished via telecommunications technology at the same rate they are paid for in-person mental health visits (that is, the AIR or FQHC PPS).

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 214-215, (Accessed Sept 2022).

FQHCs bill G0470 (or other appropriate FQHC specific mental health visit payment code) with Modifiers 95 (audio-video) or FQ (audio-only).

SOURCE: Mental Health Visits via Telecommunications for Rural Health Clinics and Federally Qualified Health Centers, MLN Matters SE22001, (June 6, 2022), (Accessed Sept. 2022).

Virtual Communication Services: 

Medicare requires FQHCs submit HCPCS code G2012 (communication technology-based services), and HCPCS code G2010 (remote evaluation services) virtual communication services claims, when the virtual communication HCPCS code, G0071, is on an FQHC claim alone or with other payable services.

SOURCE: CMS MLN Booklet, Federally Qualified Health Center, Jan. 2021, pg. 9 (Accessed Sept. 2021).

READ LESS

Alabama

Last updated 11/15/2022

No reference found.

No reference found.

READ LESS

Alaska

Last updated 11/17/2022

No reference found.

No reference found.

READ LESS

Arizona

Last updated 10/19/2022

No reference found.

No reference found.

READ LESS

Arkansas

Last updated 10/17/2022

No reference found.

No reference found.

READ LESS

California

Last updated 09/06/2022

Video synchronous and audio-only synchronous visits and visits using an …

Video synchronous and audio-only synchronous visits and visits using an asynchronous store and forward modality shall be reimbursed at the applicable FQHC’s per-visit PPS rate to the extent the department determines that the FQHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter and 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).

READ LESS

Colorado

Last updated 10/21/2022

A telemedicine service meets the definition of a face-to-face encounter …

A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, Indian health service, or federally qualified health center.  The reimbursement rate for a telemedicine service provided by a rural health clinic or federal Indian health service or federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

SOURCE:  CO Statute, Sec. 25.5-5-320. (Accessed Oct. 2022).

Generally, FQHCs get PPS from CO Medicaid: The Department will perform an annual reconciliation to ensure each FQHC has been paid at least their per visit Prospective Payment System (PPS) rate.

SOURCE: Colorado Adopted Rule 8.700.6.D. (Accessed Oct. 2022).

READ LESS

Connecticut

Last updated 08/10/2022

All covered telehealth services provided by an FQHC are paid …

All covered telehealth services provided by an FQHC are paid at the same encounter rate referenced in the state plan that would be paid to the FQHC for comparable in-person services.

SOURCE: CT Department of Social Services. FQHC Medicaid Reimbursement. (Accessed Aug. 2022).

Medical and Behavioral Health Federally Qualified Health Centers (FQHCs) are eligible to bill their encounter rate when an approved, medically necessary telemedicine service is rendered.

SOURCE: CT Policy – Provider Bulletin 2020-09. P. 5, March 2020. (Accessed Aug. 2022).

“Encounter rate” means the all-inclusive PPS rate that the Department reimburses a FQHC for an encounter pursuant to 42 USC 1396a (bb).

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

READ LESS

Delaware

Last updated 08/24/2022

There is no explicit language that the FQHC will be …

There is no explicit language that the FQHC will be paid its PPS rate.

General instructions state that the FQHC must bill the DMAP using an FQHC HCPCS (Healthcare Common Procedure Coding System) “G” visit payment code for each payable encounter visit, along with a HCPCS code for each service provided. These codes are accepted for dates of service on or after 09/01/2017. Claims must be submitted with the correct Place of Service (POS).

The payment methodology for FQHCs will conform to the BIPA 2000 Requirements Prospective Payment System (PPS). Effective July 1, 2018, Delaware will reimburse each FQHC per-visit through one of the following two (2) methodologies, whichever nets the greater result: 1. A prospective payment system (PPS) rate, where 100 percent of the reasonable costs based upon an average of their fiscal years 1999 and 2000 audited cost reports are inflated annually by the Medicare Economic Index (MEI); or 2. The per-visit cost as reported by the FQHC in its most recent cost report, subject to an audit performed by a certified public accountant as to the reasonableness of the reported costs.

SOURCE: DE FQHC Policy Manual, 10/1/21, p. 9, 11. (Accessed Aug. 2022).

READ LESS

District of Columbia

Last updated 09/03/2022

Where an FQHC provides an allowable healthcare service at the …

Where an FQHC provides an allowable healthcare service at the originating or distant site, the FQHC shall be reimbursed the applicable rate (PPS, APM or FFS).  If an FQHC is both the originating and distant site, and both sites render the same healthcare service, only the distant site will be reimbursed.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.24, 25, 26 & 27. (Accessed Sept. 2022).

In accordance with the District’s Prospective Payment System (PPS) or alternative payment methodology (APM) for FQHCs, the following reimbursement parameters apply:

  • Originating Site: An FQHC provider must deliver an FQHC-eligible service in order to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site;
  • Distant Site: An FQHC provider must deliver an FQHC-eligible service that is listed in Appendix A in order to be reimbursed the appropriate PPS, APM, or FFS rate; and
  • Originating and Distant Site: If both the originating and the distant site are FQHCs, for both to receive reimbursement, each site must deliver a different PPS or APM service (e.g. medical or behavioral). If both sites submit a claim for the same PPS or APM service (e.g. medical), then only the distance site will be eligible to receive reimbursement.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 4.Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.5, P. 52. FQHC Billing Manual, DC Medicaid 15.2.5, P. 50-51. (Aug. 24, 2022). & Physicians Billing Manual. DC Medicaid. Jun. 7, 2022. Sec. 15.10.5. P. 67. (Accessed Sept. 2022).

D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.8 Physicians Billing Manual. DC Medicaid. Jun. 7, 2022, Sec. 15.10.3-4. P. 66-67 &Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 7, 2022, pg. 3-4., Clinic Billing Manual, DC Medicaid (Aug. 24, 2022), Sec. 15.2.3-4, P. 51-52. & FQHC Billing Manual, DC Medicaid 15.2.3-4, P. 50. (Aug. 24, 2022). (Accessed Sept. 2022).

If an FQHC does not elect the APM, it will be paid the PPS for every encounter, regardless of the type of encounter. New FQHC providers will be reimbursed at the PPS rate. 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.

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

READ LESS

Florida

Last updated 10/26/2022

No explicit reference to telehealth found.

Florida Medicaid reimburses for …

No explicit reference to telehealth found.

Florida Medicaid reimburses for services provided through the fee-for-service delivery system at an encounter rate. Costs relating to the following services are excluded from the encounter rate: Ambulance services; Home health services; WIC certifications and recertifications; Any health care services rendered away from the center, at a hospital, or a nursing home. (These services include off- site radiology services and off- site clinical laboratory services. However, the health care rendered away from the center may be billed under other Florida Medicaid programs, if eligible.)

SOURCE: FL Admin Code 59G-4.100, FL Admin Code 59G-4.280, & Florida FQHC and RHC Reimbursement Plan. July 1, 2014. (Accessed Oct. 2022).

Medicaid reimburses for ambulatory primary care health care and related diagnostic services to a medically underserved population.

Medicaid reimburses up to three encounters per day, per recipient for the following:

  • Adult health screenings
  • Behavioral health
  • Child Health Check-Up screenings
  • Chiropractic
  • Dental
  • Family planning
  • Immunizations
  • Medical primary care
  • Prenatal care and obstetric care
  • Optometric
  • Podiatry
  • Registered nurse services

This service is one of the minimum covered services for all Managed Medical Assistance plans serving Medicaid enrollees.

SOURCE: AHCA FL Medicaid’s Covered Services and HCBS Waivers – FQHC Services. (Accessed Oct. 2022).

READ LESS

Georgia

Last updated 10/22/2022

There is no explicit reference to PPS rate for telehealth …

There is no explicit reference to PPS rate for telehealth found. FQHCs may bill “the cost of the visit.”

In order for the FQHC and RHC per visit rate to be paid as a PPS visit one of the CPT procedure codes listed in Appendix H must be recorded on a claim.

Reimbursement for Federally Qualified Health Center Services is based on an actual clinic encounter or visit (office, emergency room or hospital) even though other services are rendered at the same time. Federally Qualified Health Center Services are reimbursed according to the clinic’s assigned “all inclusive” rate.

SOURCE:  Georgia Department of Community Health, Division of Medicaid, Telehealth Guidance, p. 42 (Oct 1, 2022). Georgia Department of Community Health, Division of Medicaid, Federally Qualified Health Center Services and Rural Health Clinic Services, p. C-1, G-5 (Oct 1, 2022). (Accessed Oct. 2022).

READ LESS

Hawaii

Last updated 10/29/2022

PPS will be paid as follows:

  • When the patient is

PPS will be paid as follows:

  • When the patient is at the spoke/originating site, that is a FQHC (or their residence), and the provider of FQHC services is at the hub/distant site where the service is performed, which is also a FQHC, the hub/distant site will be paid PPS.
  • When the patient is at the spoke/originating site that is not a FQHC (and not their residence) and the provider of services is at the hub/distant where the service is performed, which is a FQHC, the hub/Distant site will be paid FFS.
  • If PPS eligible services are performed at a FQHC spoke/originating site and services are provided by a Medicaid provider contracted by the FQHC at a non-FQHC site, the spoke/originating site gets PPS and shall compensate the contracted provider for the services that were performed.
  • When a spoke or originating site is solely used to facilitate tele-health, payment for the facilitation shall not exceed the published Medicare rate for transmission services for spoke sites.

SOURCE: MedQUEST Memo QI-2007/FFS 20-03 (March 16, 2020). (Accessed Oct. 2022).

Dentistry:

Eligible codes for reimbursement are listed in Attachment A.  All claims for services provided through telehealth technology must be identified by the applicable teledentistry CDT code D9995 or D9996.

CDT code D9999 must be used to identify the claim for PPS payment by FQHCs and RHCs.

SOURCE: HI Med-QUEST Medicaid Provider Manual: Dental, pg. 82 (Jan. 2021)., HI Department of Human Services.  Med-QUEST Division.  Attachment A., HI MedQUEST Division, CTR 19-01 Reimbursement for Procedures Related to FQHC Teledentistry Services. (Accessed Oct. 2022).

 

READ LESS

Idaho

Last updated 08/22/2022

The services of Indian Health Services (IHS), Federally Qualified Health …

The services of Indian Health Services (IHS), Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) are a covered benefit under Idaho Medicaid. Covered services are indicated on the Idaho Medicaid Numerical Fee Schedule with a reimbursement amount. Services that qualify as described in the Encounters section shall be billed at the encounter rate.

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

READ LESS

Illinois

Last updated 11/18/2022

Clinic Reimbursement

A)        An encounter clinic serving as the originating …

Clinic Reimbursement

A)        An encounter clinic serving as the originating site shall be reimbursed for its medical encounter as defined in Section 140.462.  The clinic is responsible for reimbursement to the distant site provider.

B)        An encounter clinic serving as the distant site shall be reimbursed as follows:

  • If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department.  The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic; and
  • If the originating site is not an encounter clinic, the distant site encounter clinic shall be reimbursed for its medical encounter.  The originating site provider will receive a facility fee as defined in subsection (a)(4) of this Section.

SOURCE: IL Admin. Code Title 89, 140.403(c)(3) (Accessed Nov. 2022).

Telehealth Billing Examples:

Example 1:

Originating Site – Encounter clinic

Bill the encounter HCPCS Code T1015 and HCPCS Code Q3014, along with any additional appropriate detail code(s). Maximum reimbursement will be the facility’s medical encounter rate.

Reimbursement will be the facility’s medical encounter rate

Distant Site – Encounter clinic

There is no billable service; the Originating Encounter clinic is responsible for payment to the Distant Encounter clinic provider

Example 2:

Originating Site – Encounter clinic

Bill the encounter HCPCS Code T1015 and HCPCS Code Q3014, along with any additional appropriate detail code(s). Maximum reimbursement will be the facility’s medical encounter rate.

Distant Site – Physician’s office/APN/Podiatrist’s Office

There is no billable service; the Originating Encounter clinic is responsible for payment to the Distant Encounter clinic provider

Example 3:

Originating Site – Physician’s office/APN/Podiatrist’s Office

Bill HCPCS Code Q3014

Distant Site – Encounter clinic

Bill the encounter HCPCS Code T1015 and any appropriate detail code(s) with modifier GT on the detail line(s); POS 02. Maximum reimbursement will be the facility’s medical encounter rate. The rendering provider’s name and NPI must also be reported on the claim.

SOURCE: IL Department of Healthcare and Family Services, All Providers Supplement (Sept. 23, 2020). (Accessed Nov. 2022).

READ LESS

Indiana

Last updated 10/30/2022

In either case, reimbursement for the encounter code (T1015 or …

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 (Sept. 27, 2022), p. 6.  (Accessed Oct. 2022).

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], Portal dental claim or 837D transaction) using HCPCS encounter code D9999 – Unspecified adjunctive procedure, by report. This guidance applies for dates of service on or after July 1, 2021.

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

* Note: POS codes 02, 03 and 04 were added as allowable for valid FQHC and RHC encounter claims effective July 1, 2021.

FQHC and RHC claims submitted with a POS code of 02, 03, 04, 11, 12, 31, 32, 50 or 72 that do not include the T1015 or D9999 encounter code are denied for EOB 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 encounters provided by telehealth, FQHC and RHC providers must use POS code 02 with both the encounter code (T1015 or D9999) as well as the procedure codes for the specific allowable services provided during the telemedicine encounter. Modifier 95 is also required for all services provided via telehealth, with the exception of dental services.

SOURCE: IHCP Federally Qualified Health Centers and Rural Health Clinics Provider Reference Module (Jan 1, 2022, published May 19, 2022), p. 3-5 (Accessed Oct. 2022).

READ LESS

Iowa

Last updated 10/25/2022

No reference found.

No reference found.

READ LESS

Kansas

Last updated 08/24/2022

Providers who are not RHC or FQHC providers and are …

Providers who are not RHC or FQHC providers and are acting as the distant site will be reimbursed in accordance with a percentage of the Physician Fee Schedule and not an encounter rate.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, FQHC/RHC, 8-13 (Aug. 2022), (Accessed Aug. 2022). 

READ LESS

Kentucky

Last updated 10/31/2022

If the telehealth service or telehealth consultation provider is employed …

If the telehealth service or telehealth consultation provider is employed by the rural health clinic, federally qualified health center, or federally qualified health center look-alike, include a supplemental reimbursement paid by the Department for Medicaid Services in an amount equal to the difference between the actual reimbursement amount paid by a Medicaid managed care organization and the amount that would have been paid if reimbursement had been made directly by the department.

SOURCE: KY Revised Statute Sec. 205.559. (Accessed Oct. 2022).

READ LESS

Louisiana

Last updated 11/08/2022

Reimbursement for service codes appropriate to telemedicine/telehealth will be at …

Reimbursement for service codes appropriate to telemedicine/telehealth will be at the all-inclusive prospective payment rate on file for the date of service (DOS).

SOURCE: LA Dept. of Health, Informational Bulletin 20-1. (May 20, 2022). (Accessed Nov. 2022). 

READ LESS

Maine

Last updated 10/18/2022

Telehealth Services may be included in a Federally Qualified Health …

Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by HRSA and the State. If approved, these facilities may serve as the provider site and bill under the encounter rate.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 13. (June 15, 2020). (Accessed Oct. 2022).

READ LESS

Maryland

Last updated 11/22/2022

No explicit telehealth reference found.

Federally qualified health centers shall …

No explicit telehealth reference found.

Federally qualified health centers shall be reimbursed for covered services once the provider is in compliance with all federal and State requirements. Federally qualified health centers shall be paid 100 percent of the FQHC’s allowable costs, which will be determined in accordance with Medicare principles of cost reimbursement as contained in 42 CFR 413.5, unless otherwise specified in this chapter. Reimbursement to providers of federally qualified health center services shall be on a per-visit basis. The Department or its designee shall establish an all-inclusive interim and an all-inclusive final cost-per-visit rate for each provider. Each provider shall have a rate established for primary care services. A rate for dental care services shall be established if the service is offered. The all-inclusive cost-per-visit rate for primary care visits covers the allowable costs associated with covered primary care, mental health, and substance abuse services. FQHCs may not charge the program, other than an all-inclusive cost-per-visit rate, for any ambulatory service. Non-reimbursable costs are those costs that are not reimbursable under this payment methodology.

SOURCE: COMAR 10.09.08.08. (Accessed Nov. 2022).

From July 1, 2021, to June 30, 2023, when appropriately provided through telehealth, the Program shall provide reimbursement in accordance on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

  • Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
  • Any room and board fees.

The Department may adopt regulations to carry out this section.

SOURCE: MD Health General Code 15-141.2 (g)(3), (h). (Accessed Nov. 2022).

READ LESS

Massachusetts

Last updated 11/17/2022

No reference found

No reference found

READ LESS

Michigan

Last updated 11/22/2022

A Tribal facility may choose to enroll as a Tribal …

A Tribal facility may choose to enroll as a Tribal FQHC and be reimbursed for outpatient face-to-face visits within the FQHC scope of services provided to Medicaid beneficiaries, including telemedicine and services provided by contracted employees. Tribal FQHCs are eligible to receive the IHS outpatient AIR for eligible encounters.

SOURCE: Dept. of Health and Human Services Medicaid Provider Manual, p. 2122, Oct. 1, 2022 (Accessed Nov. 2022). 

READ LESS

Minnesota

Last updated 10/24/2022

No explicit reference found regarding whether or not FQHCs can …

No explicit reference found regarding whether or not FQHCs can receive PPS for telehealth delivered service.  However, face-to-face services (which typically allow for the PPS rate) does include telehealth, according to the FQHC manual.

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

READ LESS

Mississippi

Last updated 11/17/2022

The Division of Medicaid reimburses for telehealth services which meet …

The Division of Medicaid reimburses for telehealth services which meet the requirements of Miss. Admin. Code Part 225 as follows:

  • An encounter for face-to-face telehealth services provided by the FQHC acting as a distant site provider.
  • The FQHC may not bill for an encounter visit unless a separately identifiable service is performed.
  • Reimburses a FQHC for both the distant and originating provider site when such services are appropriately provided by the FQHC.

The Division of Medicaid defines an encounter rate as a prospective payment system (PPS) rate per encounter.

SOURCE: MS Admin. Code Title 23, Part 211, Rule. 1.1 & 1.5. (Accessed Nov. 2022).

READ LESS

Missouri

Last updated 08/19/2022

No reference found

No reference found

READ LESS

Montana

Last updated 11/01/2022

No reference found.

No reference found.

READ LESS

Nebraska

Last updated 11/18/2022

FQHC and RHC payment for telehealth services is the Medicaid …

FQHC and RHC payment for telehealth services is the Medicaid rate for a comparable in-person service. FQHC & RHC core services provided via telehealth are not covered under the encounter rate.

SOURCE: NE Admin. Code Title 471, Sec. 29-003.1 & Sec. 29-004.05, Ch. 29. (Accessed Nov. 2022).  

READ LESS

Nevada

Last updated 11/03/2022

No reference found.

No reference found.

READ LESS

New Hampshire

Last updated 11/10/2022

No reference found

No reference found

READ LESS

New Jersey

Last updated 09/06/2022

Statute requires NJ Medicaid to cover telemedicine or telehealth on …

Statute requires NJ Medicaid to cover telemedicine or telehealth on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable when services are delivered through in-person contact and consultation, provided the services are otherwise covered when delivered through in-person contact and consultation in New Jersey.  There is no explicit confirmation that from NJ Medicaid that this provision has been implemented or that they are reimbursing the PPS rate for FQHCs.

SOURCE: NJ Statute C.30:4D-6K. (Accessed Sept. 2022).

READ LESS

New Mexico

Last updated 10/28/2022

No reference found

No reference found

READ LESS

New York

Last updated 08/25/2022

When services are provided via telemedicine to a patient located …

When services are provided via telemedicine to a patient located at an FQHC originating site, the originating site may bill only the FQHC offsite services rate code (4012) to recoup administrative expenses associated with the telemedicine encounter. When a separate and distinct medical service, unrelated to the telemedicine encounter, is provided by a qualified practitioner at the FQHC originating site, the originating site may bill the Prospective Payment System (PPS) rate in addition to the FQHC offsite services rate code (4012).

If a provider who is onsite at an FQHC is providing services via telemedicine to a member who is in their place of residence or other temporary location, the FQHC should bill the FQHC off-site services rate code (4012) and report the applicable modifier (95 or GT) on the procedure code line.

If the FQHC is providing services as a distant site provider, the FQHC may bill their PPS rate.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 11. (Accessed Aug. 2022).

READ LESS

North Carolina

Last updated 11/03/2022

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) …

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth.

FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring.

Core visit services delivered via telehealth are billed under the FQHC and RHC provider number using the HCPCS code T1015 (clinic visit/encounter, all-inclusive), T1015-HI (for behavioral health services), or T1015-SC (subsequent sick visit) and appended with the GT modifier. Eligible providers include all core service providers as defined in Section 3.2.1 of this policy, which includes physicians, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, licensed psychological associates, licensed clinical mental health counselors, licensed marriage and family therapists, advance practice nurse specialists, clinical nurse specialists, and licensed clinical addiction specialists.

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, pgs.8-9 & 19 Dec. 1, 2020. (Accessed Nov. 2022).

READ LESS

North Dakota

Last updated 11/08/2022

While there is an explicit reference to Indian Health Service …

While there is an explicit reference to Indian Health Service facilities or Tribal 638 clinics receiving the all-inclusive rate (AIR), there is no reference found for FQHCs.

SOURCE: ND Div. of Medical Assistance, General Information Provider Manual, Telemedicine, p. 158, (Oct. 2022), (Accessed Nov. 2022). 

READ LESS

Ohio

Last updated 09/07/2022

Medical nutrition therapy and lactation services rendered by eligible FQHC

Medical nutrition therapy and lactation services rendered by eligible FQHC and RHC practitioners will be paid under the PPS.

Group therapy will continue to be paid through FFS as a covered non-FQHC/RHC service under the clinic provider type 50 (using ODM’s payment schedules).

Services under the Specialized Recovery Services (SRS) program are not currently covered FQHC or RHC services.

READ LESS

Oklahoma

Last updated 09/05/2022

No reference found

No reference found

READ LESS

Oregon

Last updated 11/10/2022

No reference found.

No reference found.

READ LESS

Pennsylvania

Last updated 09/06/2022

MA MCOs may also cover teledentistry visits and encounters. MA …

MA MCOs may also cover teledentistry visits and encounters. MA MCOs may negotiate payment for services rendered via telemedicine. FQHCs and RHCs that have opted into the Alternative Payment Methodology (APM) will receive at least their provider-specific MA FFS Prospective Payment System (PPS) rate for a dental encounter from the MA MCO. If the FQHC or RHC has not opted into this APM, then the Department will make supplemental payments to the provider that equal the difference between the payment under the PPS rate and the payment provided by the MA MCO.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin, Teledentistry Guidelines and Dental Fee Schedule Updates (May 2, 2022). (Accessed Sept. 2022).

READ LESS

Puerto Rico

Last updated 09/08/2022

No reference found.

No reference found.

READ LESS

Rhode Island

Last updated 10/21/2022

No reference found

No reference found

READ LESS

South Carolina

Last updated 08/12/2022

The RHCs and FQHCs would bill an encounter code when …

The RHCs and FQHCs would bill an encounter code when operating as the consulting site. Only one encounter code can be billed for a DOS. Both provider types will use the appropriate encounter code for the service along with the “GT” modifier (via interactive audio and video telecommunications system) indicating interactive communication was used.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 215 (July 2022). (Accessed Aug. 2022).

All medical encounters must be billed using the appropriate encounter code unless otherwise specified. A medical “visit” (encounter) is defined as a face-to-face encounter between a patient and the physician, PA, NP, chiropractor or CNM during which an FQHC core service is provided. FQHC providers will be reimbursed their contracted encounter rate, and are allowed only one medical encounter per day, even if the patient sees more than one professional at the visit or on that day. The use of this code counts toward the ambulatory visit limit for beneficiaries age 21 or older.

All maternal care encounters must be billed with the appropriate encounter code with a TH modifier. FQHC providers will be reimbursed their contracted rate for all maternal services rendered.

SCDHHS allows FQHCs to bill for HIV/AIDS and cancer-related services using the appropriate encounter code, with the P4 modifier.

The FQHC laws established a set of health care services called “FQHC services” for which Medicare and/or Medicaid must cover on a reasonable cost basis when provided by an FQHC. Encounter services are referred to as FQHC core services. Core services are reimbursed using encounter codes.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 142, 260 (July 2022). (Accessed Aug. 2022).

READ LESS

South Dakota

Last updated 11/10/2022

Reimbursement for distant site telemedicine services is limited to the …

Reimbursement for distant site telemedicine services is limited to the individual practitioner’s professional fees or the encounter rate if the service qualifies as an FQHC/RHC or IHS/Tribal 638 clinic service. The maximum allowable amount for services provided via telemedicine is the same as services provided in-person.

 SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 11 (Sept. 2022), (Accessed Nov. 2022),

READ LESS

Tennessee

Last updated 09/04/2022

No reference found

No reference found

READ LESS

Texas

Last updated 09/07/2022

FQHCs may be reimbursed the distant-site provider fee for telemedicine …

FQHCs may be reimbursed the distant-site provider fee for telemedicine services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.

FQHCs providing distant-site telehealth services may be reimbursed as the following:

  • FQHCs may be reimbursed the distant-site provider fee for telehealth services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.
  • FQHC practitioners may be employees of the FQHC or contracted with the FQHC.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 10 & 13. (Sept 2022), (Accessed Sept. 2022).

READ LESS

Utah

Last updated 08/23/2022

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

FQHC Provider manual refers providers to Federal regulations (Title 42, Subpart X) for definitions specific to FQHCs.  Federal regulations contains a section on supplemental payment for interactive, real-time, audio and video telecommunications technology or audio-only interactions. Unclear if this policy applies in Utah Medicaid. See next citation.

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).

READ LESS

Vermont

Last updated 10/27/2022

No Reference Found.

No Reference Found.

READ LESS

Virgin Islands

Last updated 09/08/2022

No reference found.

No reference found.

READ LESS

Virginia

Last updated 11/23/2022

Telehealth services may be included in a Federally Qualified Health …

Telehealth services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by HRSA and the Commonwealth. If approved, these facilities may serve as the Provider or originating site and bill under the encounter rate. The encounter rate methodology for FQHCs and RHCs is described in 12VAC30-80-25; the encounter rate for IHCs (including Tribal clinics) is the All Inclusive Rate set by Indian Health Services.

SOURCE:  VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022).

READ LESS

Washington

Last updated 08/26/2022

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

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.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 9, (Aug. 2022); Federally Qualified Health Centers, p. 9 (Aug. 2022), (Accessed Aug. 2022).

FQHCs may receive the encounter rate when billing as a distant site provider if the service being billed is encounter eligible. Clients enrolled in an agency-contracted MCO must contact the MCO regarding whether or not the plan will authorize telemedicine coverage.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Rural Health Clinics, p. 46, (Aug. 2022)Federally Qualified Health Centers, p. 62. (Aug. 2022), (Accessed Aug. 2022).

Encounter rate: A cost-based, facility-specific rate for covered FQHC services paid to an FQHC for each valid encounter it bills.

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

READ LESS

West Virginia

Last updated 09/02/2022

FQHCs or RHCs may now serve as a distant site …

FQHCs or RHCs may now serve as a distant site for Telehealth consultations by a psychiatrist or psychologist only and be reimbursed at the encounter rate. The distant-site practitioner must bill the appropriate Current Procedural Technology/Healthcare Common Procedure Coding System (CPT/HCPCS) code with the appropriate Place of Service on a HCFA1500 form.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual. Chapter 522.8 Federally Qualified Health Center and Rural Health Clinic Svcs. P. 9. (July 1, 2019). (Accessed Sept. 2022).

READ LESS

Wisconsin

Last updated 11/21/2022

Services billed with modifier GT, FQ, or 93 will be …

Services billed with modifier GT, FQ, or 93 will be considered under the PPS reimbursement method for non-tribal FQHCs. Billing HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for fee-for-service encounters. Fee-for-service claims must include HCPCS procedure code T1015 when services are provided via telehealth in order for proper reimbursement.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth, (Accessed Nov. 2022).

READ LESS

Wyoming

Last updated 10/20/2022

No reference found

No reference found

READ LESS

Federally Qualified Health Center (FQHC)

PPS Rate

jump to: