Federally Qualified Health Center (FQHC)

PPS Rate

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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 12/14/2023

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. 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 Dec. 2023).

FQHCs bill G0470 (or other appropriate FQHC specific mental health visit payment code) with Modifiers 95 (audio-video) or FQ  or 93 (audio-only).  They can also bill 90834 (or other FQHC Prospective Payment System (PPS) qualifying mental health visit payment code), both with Revenue Code 0900.

SOURCE: Mental Health Visits via Telecommunications for Rural Health Clinics and Federally Qualified Health Centers, MLN Matters SE22001, (May 23, 2023), (Accessed Dec. 2023).

 

* The US Health and Human Services Administration maintains a website that summarizes information for Billing Medicare as a safety-net provider.

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Alabama

Last updated 02/26/2024

No reference found.

No reference found.

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Alaska

Last updated 02/27/2024

No reference found.

No reference found.

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Arizona

Last updated 02/09/2024

No reference found.

No reference found.

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Arkansas

Last updated 02/06/2024

Effective for dates of service on and after January 1, …

Effective for dates of service on and after January 1, 2003, the procedure codes listed in this manual, the Child Health Services (EPSDT) provider manual and the ARKids First-B Provider Manual (with the exception of the FQHC encounter procedure code and the telemedicine procedure code) will be initially reimbursed in accordance with the Arkansas Medicaid fee schedule, at the lesser of the billed charge or the Medicaid maximum allowable fee.

The telemedicine procedure code and procedure codes for ancillary services, except for family planning-related laboratory procedures listed in this manual, will be denied.

SOURCE:  AR Medicaid Provider Manual. Section II FQHC. Rule 262.120. Updated Oct. 13, 2003. pg. II-26, II-32 (Accessed Feb. 2024).

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California

Last updated 12/20/2023

Telehealth services are billed utilizing existing claiming processes that include …

Telehealth services are billed utilizing existing claiming processes that include billing the appropriate managed care plan first. If applicable, once the managed care plan payment is received, submit the claim to the Med-Cal Fiscal Intermediary for the Prospective Payment System (PPS) rate wrap.

Only one visit or store and forward service may be billed at the PPS rate when there is a service payment contract with a non-FQHC/RHC, contractor, or another FQHC or RHC. Conversely, the non-FQHC/RHC or contractor may request fee-for-service reimbursement for a visit or store and forward service directly from the appropriate managed care plan or the Medi-Cal Fiscal Intermediary if no service payment contract exists with the FQHC or RHC.

SOURCE: CA Dept. Health Care Services, Medi-Cal Provider Manual, Part 2: RHC and FQHC (Jan. 2023), p. 15. (Accessed Dec. 2023).

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) (Accessed Dec. 2023).

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Colorado

Last updated 01/29/2024

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 Jan. 2024).

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 Jan. 2024).

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Connecticut

Last updated 01/10/2024

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 Jan. 2024).

Federally Qualified Health Centers (FQHCs) are eligible to bill their encounter rate when an approved, medically necessary telehealth service is rendered. FQHCs must use the services identified on the CMAP Telehealth Table in combination with their approved scope of service to identify the services eligible to be rendered using telehealth. FQHCs must continue to bill HCPCS code, T1015 and all eligible telehealth procedure codes to reflect all of the services rendered during the telehealth visit.

SOURCE: CMAP Telehealth Table. (Accessed Jan. 2024).

“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 Jan. 2024).

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Delaware

Last updated 01/15/2024

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, 7/1/23, p. 10, 12. (Accessed Jan. 2024).

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District of Columbia

Last updated 12/07/2023

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 Dec. 2023).

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. 2023, pg. 4-5.,Physicians Billing Manual.  DC Medicaid.  (Sept. 2023) Sec. 15.5. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.5, P. 51. FQHC Billing Manual, DC Medicaid 15.5, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Sept. 2023) 14.5, p. 69. Inpatient Hospital Billing Guide, 11.5, p. 62 (Sept. 2023), Long-Term Care Billing Manual, 15.5, p. 53 (Sept. 2023) (Accessed Dec. 2023).

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 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4. Physicians Billing Manual.  DC Medicaid.  (Sept. 2023) Sec. 15.4. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50. FQHC Billing Manual, DC Medicaid 15.4, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Sept. 2023) 14.4, p. 68., Outpatient Hospital Billing Guide, 15.8.4, p. 75 (Sept. 2023), Inpatient Hospital Billing Guide, 11.4, p. 61 (Sept. 2023), Long-Term Care Billing Manual, 15.4, p. 52 (Sept. 2023). (Accessed Dec. 2023).

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 17.1, P. 67-68. (Oct. 2023). (Accessed Dec. 2023).

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Florida

Last updated 02/23/2024

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, & Florida FQHC and RHC Reimbursement Plan. July 1, 2014. (Accessed Feb. 2024).

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 Feb. 2024).

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Georgia

Last updated 01/31/2024

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. 38 (Jan. 1, 2024). Georgia Department of Community Health, Division of Medicaid, Federally Qualified Health Center Services and Rural Health Clinic Services, p. 23, C-1, G-5 (Jan. 1, 2024). (Accessed Jan. 2024).

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Hawaii

Last updated 02/13/2024

The criteria for sites eligible to receive PPS payment is …

The criteria for sites eligible to receive PPS payment is the same for services furnished in-person and by telehealth modality. Services provided through telehealth which are eligible for PPS payment must be for services that are approved within the scope of the specific FQHC’s PPS reimbursement rate. The services must be provided at the FQHC’s HRSA approved site or satellite.

With exceptions, the FQHC provider must be located at their contracted FQHC’s HRSA approved site or satellite. Exceptions:

Until December 31, 2024, FQHC behavioral health providers may be located at a non-HRSA approved site or satellite within the United States and the United States’ territories.

  • If the FQHC behavioral health provider does not have the capacity to provide in-person services, they must inform the patient that: the patient has the right to receive in-person services if they prefer; they (the provider) are incapable of providing in-person services; and they (the provider) must inform the patient that their QI MCO can assist with finding a provider who can provide in-person services.
  • If prescribing controlled substances, the provider must be located in the State of Hawai’i.

FQHCs must ensure the provision of relevant wrap-around non-billable services. Efforts shall be made to ensure that patients receive relevant wrap-around non-billable services, and this may mean delivering care to the patient’s location as one way to ensure services are received. Wrap-around non-billable services may or may not occur on the same day as services provided through telehealth modality and the eligible FQHC provider delivering services through the telehealth modality must provide clear instructions to the patient on how and when the wrap-around non-billable services will be provided. Wrap-around non-billable services must be documented in the patient’s medical record.

SOURCE: Med-QUEST Memo QI-2338/FFS 23-22/CCS-2311.  (Accessed Feb. 2024).

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. 108 (Jan. 2023)., HI Department of Human Services.  Med-QUEST Division.  Attachment A., HI MedQUEST Division, FFS 19-01 Reimbursement for Procedures Related to FQHC Teledentistry Services. (Accessed Feb. 2024).

 

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Idaho

Last updated 02/13/2024

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. Amounts of $0.00 are covered and require manual pricing per the General Billing Instructions, Idaho Medicaid Provider Handbook. Services must meet the criteria for the procedure found in the Physician and Non-Physician Practitioner and Hospital, Idaho Medicaid Provider Handbooks. Certain procedures must be prior authorized to be covered. See the Prior Authorizations section for more information. 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 (Nov. 18 2022)., p. 15.  (Accessed Feb. 2024).

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Illinois

Last updated 02/27/2024

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 Feb. 2024).

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). Encounter Clinic Services – Appendices. (Accessed Feb. 2024).

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Indiana

Last updated 12/05/2023

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 Dec. 2023).

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 Dec. 2023).

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Iowa

Last updated 01/15/2024

No reference found.

No reference found.

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Kansas

Last updated 12/06/2023

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, 8-14 (Aug. 2023), (Accessed Dec. 2023).

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Kentucky

Last updated 12/11/2023

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 Dec. 2023).

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Louisiana

Last updated 02/15/2024

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 Feb. 2024).

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Maine

Last updated 02/03/2024

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 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. 12. (Nov. 6, 2023). (Accessed Feb. 2024).

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Maryland

Last updated 02/21/2024

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 Feb. 2024).

From July 1, 2021, to June 30, 2025, 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), as amended by HB 1148/SB 582/SB 534 (2023 Session). (Accessed Feb. 2024).

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Massachusetts

Last updated 01/12/2024

Rates of payment for services delivered via telehealth will be

Rates of payment for services delivered via telehealth will be the same as the rates of payment for services delivered via traditional (i.e., in-person) methods as set forth in the applicable regulations.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Jan. 2024).

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Michigan

Last updated 01/19/2024

Telemedicine services provided at the distant site that qualify as …

Telemedicine services provided at the distant site that qualify as a face-to-face visit may generate the PPS payment. All current PPS rules and encounter criteria apply to telemedicine visits. Refer to the FQHC/RHC telemedicine services billing chart for billing rules.

SOURCE:  MI Dept. of Health and Human Services. Bulletin 20-09, General Telemedicine Policy, Mar. 12, 2020, [Provider Bulletin 23-10 indicates policy is permanent] & Dept. of Health and Human Services Medicaid Provider Manual, p. 2152, Jan. 1, 2024 (Accessed Jan. 2024).

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. 2197, Jan. 1, 2024 (Accessed Jan. 2024).

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Minnesota

Last updated 02/29/2024

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 Feb. 2024).

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Mississippi

Last updated 12/23/2023

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 Dec. 2023).

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Missouri

Last updated 01/20/2024

No reference found

No reference found

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Montana

Last updated 02/13/2024

No reference found.

No reference found.

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Nebraska

Last updated 01/04/2024

IHS and Tribal 638 facilities can bill the encounter rate …

IHS and Tribal 638 facilities can bill the encounter rate for telehealth services as long as these services meet the definition of an encounter. The facility must stay in accordance with the four walls rule to bill for telehealth. Federally qualified health centers and rural health centers may bill the encounter rate for core services that are allowed via telehealth. Learn more about the list of allowable telehealth codes on our website.

SOURCE: NE Medicaid Program, Bulletin 23-08:  Guidance on Telehealth, Mar. 23, 2023, (Accessed Jan. 2024).

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 Jan. 2024). 

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Nevada

Last updated 12/18/2023

Providers that bill per diem or encounter rates may bill …

Providers that bill per diem or encounter rates may bill an encounter rate in lieu of the originating site fee. Per diem or encounter-based providers would not bill HCPCS code Q3014 and an encounter code, as the facility fee is already included in the per diem/encounter rates. If the telecommunication system used is a recipient’s smart phone or home computer, the facility fee may not be billed.

SOUCE: NV Medicaid Billing Instructions, 2/22/23, (Accessed Dec. 2023).

Originating Site: The FQHC may bill an encounter rate in lieu of the originating site fee, if the distant site (provider) is providing ancillary services. The originating site code, Q3014, must be used when billing in lieu of an encounter code.

Distant Site: FQHCs providing services for a recipient from a distant site may bill the appropriate encounter rate with Place of Service (POS) Code 02. Use of the POS code certifies the service meets telehealth requirements.

SOURCE: NV Medicaid FQHC Billing Guidelines. 8/30/19. (Accessed Dec. 2023).

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New Hampshire

Last updated 12/19/2023

No reference found

No reference found

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New Jersey

Last updated 02/02/2024

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 Feb. 2024).

Teledentistry (D9995) can only be billed in conjunction with CDT code D0140 – limited oral evaluation – problem focused. For Federally Qualified Health Centers – the encounter code (D0120 with modifier 22), along with D9995 and D0140, must be billed for the same date with all services submitted on the same claim.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter Vol. 33, No. 13, Aug. 2023, p. 3. (Accessed Feb. 2024).

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New Mexico

Last updated 02/26/2024

An originating clinical service fee is billed at the encounter …

An originating clinical service fee is billed at the encounter rate.

SOURCE: NM Behavioral Health Policy and Billing Manual for Providers, pg. 30, (Accessed Feb. 2024).

All specialized behavioral health services provided within the HRSA-approved scope of practice of the FQHC will be paid using the prospective payment system rate.

SOURCE: NM Behavioral Health Policy and Billing Manual for Providers, pg. 33, (Accessed Feb. 2024).

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New York

Last updated 11/18/2023

FQHCs can bill the Prospective Payment System (PPS) rate code …

FQHCs can bill the Prospective Payment System (PPS) rate code “4012” or “4013”, depending on on-site presence as outlined in “VII. Billing Rules for Telehealth Services”, “M. FFS Billing for Telehealth by Site and Location” on page 14 of the Medicaid Comprehensive Guidance. Wrap payments are available for any telehealth services, including telephonic services reimbursed by an MMC Plan, under qualifying PPS and off-site rate codes.

FQHCs that have “opted into” Ambulatory Patient Groups (APGs) should follow the billing guidance outlined for sites billing under APGs.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 39, Number 3, February 2023, p. 11, 14-15. (Accessed Nov. 2023).

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North Carolina

Last updated 12/12/2023

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, Aug. 15, 2023. (Accessed Dec. 2023).

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North Dakota

Last updated 02/19/2024

Payment to FQHCs for covered services furnished to members is …

Payment to FQHCs for covered services furnished to members is made by means of an all-inclusive rate for each encounter.   Encounter in this chapter means a face-to-face visit or synchronous telehealth visit during which a qualifying encounter service is rendered. FQHCs may furnish services that qualify as a medical, dental, or behavior health encounter. Each encounter includes services and supplies incident to the service.

SOURCE: ND Medicaid General Information, Federally Qualified Health Center, Jan. 2024, (Accessed Feb. 2024).

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Ohio

Last updated 02/16/2024

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.

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Oklahoma

Last updated 12/04/2023

An RHC and an FQHC shall be reimbursed for services …

An RHC and an FQHC shall be reimbursed for services delivered via audio-only telecommunications at the fee-for-service rate per the fee-for-service fee schedule.

SOURCE: OK Admin. Rule 317:30-3-27.1. (Accessed Dec. 2023).

As claims/encounters are filed, reimbursement for SoonerCare Choice members is made for all medically necessary covered primary care and other approved health services at the PPS rate, except for services delivered via audio-only telecommunications which are reimbursed at the fee-for-service (FFS) rate pursuant to the FFS fee schedule.

Primary and preventive behavioral health services rendered by health care professionals authorized in the Federally Qualified Health Center (FQHC) approved state plan pages will be reimbursed at the PPS encounter rate, except for services delivered via audio-only telecommunications which are reimbursed at the FFS rate pursuant to the FFS fee schedule.

SOURCE: OK Admin. Rule 317:30-3-664.10. (Accessed Dec. 2023).

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Oregon

Last updated 12/20/2023

No reference found.

No reference found.

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Pennsylvania

Last updated 01/22/2024

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 Jan. 2024).

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Puerto Rico

Last updated 12/18/2023

No specific reference to telehealth, however, generally Puerto Rico Medicaid’s …

No specific reference to telehealth, however, generally Puerto Rico Medicaid’s policy on PPS rate for FQHCs is:

FQHCs are entitle to PPS reimbursement for services provided to any individual eligible for Medicaid regardless of the existence of third party liability including Medicare. See manual for more inforamtion.

 

SOURCE: Puerto Rico Dept of Health, Reimbursement Ruling Federally Qualified Health Centers (FQHC), Medicaid Program (2019), p.  6.  (Accessed Dec. 2023).

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Rhode Island

Last updated 02/01/2024

No reference found

No reference found

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South Carolina

Last updated 02/08/2024

Telehealth services will continue to be reimbursed as a “bill-above” …

Telehealth services will continue to be reimbursed as a “bill-above” service and will be paid outside of the established encounter rate. Providers will instead receive the reimbursement rate from the applicable SCDHHS fee schedule.

SOURCE: SC Dept. of Health and Human Services. Medicaid Bulletin 23-018. (May 2023). (Accessed Feb. 2024).

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 (Feb. 2024). (Accessed Feb. 2024).

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. 143-144, 261-262 (Feb. 2024). (Accessed Feb. 2024).

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South Dakota

Last updated 12/21/2023

Providers must bill for services at their usual and customary …

Providers must bill for services at their usual and customary charge. Providers are reimbursed the lesser of their usual and customary charge or the fee schedule rate. 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 reimbursement for distant site services is listed on the applicable fee schedule. The maximum allowable amount for services provided via telemedicine is the same as services provided in-person. Facility related charges for distant site telemedicine providers are not reimbursable.

 SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, p. 11 (Dec. 2023), (Accessed Dec. 2023).

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Tennessee

Last updated 01/21/2024

No reference found

No reference found

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Texas

Last updated 01/07/2024

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

FQHCs may be reimbursed the distant-site provider fee for telemedicine/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. (Jan. 2024), (Accessed Jan. 2024).

FQHCs and RHCs may be reimbursed for telemedicine and telehealth in the following manner:

  • The distant site provider fee is reimbursable as a prospective payment system (PPS), alternative prospective payment system (APPS), or AIR (All Inclusive Rate) PPS.
  • The facility fee (procedure code Q3014) is an add-on procedure code that should not be included in any cost reporting that is used to calculate a FQHC PPS, APPS, or the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

SOURCE: TX Medicaid Healthy Texas Women Program Handbook, (Jan. 2024). (Accessed Jan. 2024).

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Utah

Last updated 02/28/2024

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, Sept. 2023, (Accessed Feb. 2024).

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Vermont

Last updated 12/05/2023

No Reference Found.

No Reference Found.

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Virgin Islands

Last updated 12/18/2023

No reference found.

No reference found.

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Virginia

Last updated 01/05/2024

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 Assistance Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals), (Oct. 2022) (Accessed Jan. 2024).

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Washington

Last updated 12/15/2023

FQHCs may receive the encounter rate when billing as a …

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.

Effective August 1, 2022, HCA pays for audio-only telemedicine services for specific procedure codes when provided and billed as directed in HCA provider billing guides. FQHCs may receive the encounter rate when billing as an audio-only code if the service being billed is encounter eligible and meets the billing requirements as outlined in the Encounters section in the FQHC Guide.

SOURCE: Federally Qualified Health Centers, p. 64. (Oct. 2023). (Accessed Dec. 2023).

Encounter rate: A cost-based, facility-specific rate for covered FQHC services .

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 8 (Oct. 2023). (Accessed Dec. 2023).

The agency or the agency’s designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) pays for encounter-eligible health care services authorized for delivery through telemedicine at the encounter rate when provided by:

  • Rural health clinics;
  • Federally qualified health centers; or
  • Direct Indian health service clinics, tribal clinics, or tribal federally qualified health centers.

SOURCE: WAC 182-501-0300(5)(b). (Accessed Dec. 2023).

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West Virginia

Last updated 02/14/2024

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 Feb. 2024).

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Wisconsin

Last updated 01/09/2024

For the purpose of this Online Handbook topic, FQHC refers …

For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.

Services billed with modifier GQ, 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 Handbook, Originating and Distant Sites, Topic #22739, (Accessed Jan. 2024).

The following apply to telehealth services:

  • Telehealth services include “originating site” services and/or “distant site” services.
  • Telehealth services are counted as encounters and require following PPS methodology guidelines.

CHC costs associated with telehealth services may be reported for change in scope adjustment consideration; therefore, telehealth service costs may be used for future rate setting purposes.

SOURCE: WI ForwardHealth Online Handbook Community Health Center Encounter Reimbursement, (Accessed Jan. 2024).

 

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Wyoming

Last updated 01/31/2024

No reference found

No reference found

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Federally Qualified Health Center (FQHC)

PPS Rate

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