Federally Qualified Health Center (FQHC)

Same Day Encounters

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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 RHCs and FQHCs that are authorized to bill under …

For RHCs and FQHCs that are authorized to bill under the reasonable cost system, encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the patient –

  • Suffers an illness or injury subsequent to the first visit that requires additional diagnosis or treatment on the same day;
  • Has a medical visit and a mental health visit on the same day; or
  • Has an initial preventive physical exam visit and a separate medical or mental health visit on the same day.

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

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Alabama

Last updated 11/15/2022

A patient may have one physical health encounter and one …

A patient may have one physical health encounter and one behavioral health (psychologist or clinical social worker) encounter on the same day. If the patient later suffers an illness or injury requiring additional diagnosis or treatment on the same date of service, a separate encounter may be billed. Dental services are limited to one dental encounter per date of service. A patient can have one dental encounter in addition to one physical health and/or behavioral health encounter on the same day.

Prior Authorization: FQHC procedure codes generally do not require prior authorization. Any service warranted outside of these codes must have prior authorization. Refer to Chapter 4, Obtaining Prior Authorization, for general guidelines.

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. Contacts with more than one health professional and multiple contacts with the same health professional, that take place on the same day and at a single location, constitute a single encounter unless the patient, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment. This does not apply to dental service; however, dental services are limited to one dental encounter per date of service. Therefore, a patient can have one dental encounter and one other encounter on the same day. Services incident to an encounter are inclusive.

Encounters are classified as either billable or non-billable. 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 the Fiscal Agent for payment through the proper filing of claims forms. 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, administering injections only, blood pressure checked only, and TB skin testing. Non-billable encounters can not be forwarded to the Fiscal Agent for payment. The costs of the non-billable encounters will be included in the allowable costs; however, the non-billable encounter will not be counted as an encounter on the cost report.

SOURCE: Ala. Admin. Code r. 560-X-56-.06  (Accessed Nov. 2022).

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Alaska

Last updated 11/17/2022

Claims with multiple units of the same procedure code for …

Claims with multiple units of the same procedure code for the same recipient, on the same date of service, by the same provider must be billed on one claim line with the total number of units reported. The criteria for same provider (billing or rendering) is based on provider type. Claims submitted with multiple claim lines, whether on a single claim or multiple claim forms, are considered duplicates for claims processing purposes will be denied.

SOURCE: AK Dept. of Health and Social Services, FQHC/RHC, Same Day, Multiple Units Billing, (6/12), Accessed Nov. 2022). 

“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). 

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Arizona

Last updated 10/19/2022

Multiple encounters with more than one practitioner within the same …

Multiple encounters with more than one practitioner within the same discipline, i.e., dental, physical, behavioral health, or with the same practitioner and which take place on the same day and at a single location, constitute a single visit unless the patient, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment. In this circumstance, the subsequent encounter is considered a separate visit. A service which is provided incident to another service, whether or not on the same day or at the same location, is considered to be part of the visit and is not reimbursed separately.

Multiple visits on the same day within the same discipline which are distinct based upon the FQHC/RHC visit definition above must be identified by billing the T1015 visit code for the same-day subsequent visit with a modifier 25 to indicate a distinct and separate visit.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10 Addendum: FQHC/RHC, (7/12/21), pg. 1 & 3, (Accessed Oct. 2022). 

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Arkansas

Last updated 10/17/2022

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

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

  • Contacts with more than one health professional and multiple contacts with the same health professional that take place on the same day and at a single location constitute a single encounter except when the patient, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment.
  • A patient of the FQHC may have a separate family planning encounter during the same visit to the FQHC for a core service encounter; however, a family planning visit is not reimbursed separately when it takes place on the same day as a family planning surgical procedure.
  • An FQHC encounter is not reimbursed separately on the same day as an obstetric or gynecologic procedure that the FQHC reports by CPT procedure code unless the encounter is for a different disorder or condition.

SOURCE:  AR Medicaid Provider Manual. Section II FQHC. Rule 252.100. Updated Oct. 13, 2003. pg. II-22, (Accessed Oct. 2022).

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California

Last updated 09/06/2022

Encounters with more than one health care professional and multiple …

Encounters with more than one health care professional and multiple encounters with the same health care professional that take place on the same day and at a single location constitute a single visit. More than one visit may be counted on the same day (which may be at a different location) in either of the following situations:

  • When a patient, after the first visit, suffers illness or injury that requires another health diagnosis or treatment
  • When a patient is seen by a health care professional or CPSP practitioner and also receives dental services on the same day

Clinic visits at which the patient receives services “incident to” physician services (for example, a laboratory or X-ray appointment) do not qualify as reimbursable visits.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Dec. 2020. Pg. 6. (Accessed Sept. 2022).

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Colorado

Last updated 10/21/2022

CPT and HCPCS codes cannot be repeated for the same …

CPT and HCPCS codes cannot be repeated for the same date of service.

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

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Connecticut

Last updated 08/10/2022

Visits with more than one health professional or allied health …

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).

Each FQHC shall bill for FQHC services per encounter. Claims are limited to one all-inclusive encounter per day to include all services received by a client on the same day unless the client suffers an illness or injury subsequent to the first encounter that requires additional diagnosis or treatment or if the client has different types of visits on the same day such as medical and dental or medical and behavioral health. Medicaid pays for one medical, one dental, and one behavioral health encounter per day.

SOURCE: CT FQHC Provider Manual, p. 14 (Oct. 1, 2020). (Accessed Aug. 2022).

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Delaware

Last updated 08/24/2022

Encounters with more than one health professional and multiple encounters …

Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit except when the patient, after the first encounter, suffers illness or injury requiring additional 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.

Exception is made for cases in which the patient, subsequent to the first “encounter” suffers illness or injury requiring additional diagnosis or treatment on the same day (42 CFR§405.2463). Exception is also made if the patient has a medical visit and another health visit for mental health services on the same day (42 CFR§405.2463(a)(3)(ii)).

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

The FQHC will receive a separate encounter rate for each …

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.

FQHCs must ensure that treatment requiring multiple procedures generally provided in a single visit are billed as a single encounter unless multiple visits are required to complete the treatment plan. Every claim should be a complete record of all services provided for the date of service.

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

Florida Medicaid reimburses for services provided through the fee-for-service delivery …

Florida Medicaid reimburses for services provided through the fee-for-service delivery system at an encounter rate. Providers may be reimbursed for up to one medical, one dental, and one behavioral health visit provided to a recipient on the same day.

SOURCE: FL Admin Code 59G-4.100. (Accessed Oct. 2022).

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).

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Georgia

Last updated 10/22/2022

Except as noted below, encounters with more than one FQHC …

Except as noted below, encounters with more than one FQHC or RHC practitioner on the same day, or multiple encounters with the same FQHC or RHC practitioner on the same day, constitute a single FQHC or RHC visit, regardless of the length or complexity of the visit, the number or type of practitioners seen, or whether the second visit is a scheduled or unscheduled appointment. This would include situations where a FQHC or RHC patient has a medically necessary face-to-face visit with a FQHC or RHC practitioner, and is then seen by another FQHC or RHC practitioner, including a specialist, for further evaluation of the same condition on the same day, or is then seen by another FQHC or RHC practitioner (including a specialist) for evaluation of a different condition on the same day. More than one medically-necessary face-to-face visit with a FQHC or RHC practitioner on the same day is payable as one visit, except for the following circumstances:

For a new patient: The new patient has a well visit (health check) billed with CPT 99381 – 99385 and an office visit CPT 99202 – 99205 will be reimbursed 1 PPS rate.

For an established patient: The established patient has a well visit (health check) billed with CPT 99391 – 99395, Modifier EP, 25 and an office visit CPT 99211 – 99212 will be reimbursed 2 PPS rates.

The established patient has a well visit (health check) billed with CPT 99391 – 99395, Modifier EP, 25 and an office visit CPT 99213 – 99215 will be reimbursed 1 PPS rate and a DEF rate as listed on the Physician Fee Schedule.

However, if the patient suffers illness or injury on the same day requiring additional diagnosis or treatment subsequent to the initial visit, another visit may be billed. In addition, separate FQHC and RHC per visit payments can be made for “core” services versus other ambulatory services provided on the same day by different types of qualified health care professionals for different procedure and diagnostic codes.

SOURCE:  Georgia Department of Community Health, Division of Medicaid, Federally Qualified Health Center Services and Rural Health Clinic Services, p. 10, C-1. (Oct 1, 2022). (Accessed Oct 2022).

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Hawaii

Last updated 10/29/2022

Federally Qualified Health Centers (FQHCs) are paid a PPS all-inclusive …

Federally Qualified Health Centers (FQHCs) are paid a PPS all-inclusive rate for all services performed by the FQHC covered health care professionals (as defined in section 21.2.1) for each encounter with a Medicaid client per day. Contacts with one or more health care professionals and multiple contacts with the same health care professional that take place on the same day and at a single location shall constitute a single encounter unless:

I.  After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment.

  • Two (2) encounters are payable when the first encounter is for treatment of an acute and/or chronic condition such as cough/ fever and/or hypertension and patient returns to the FQHC with an acute injury such laceration of the forearm, sprained ankle, etc. or
  • One (1) medical encounter is payable when the first encounter is for treatment of cough and fever and the second encounter is for a pelvic and breast exam for cancer screening.
  • One (1) medical encounter is payable when one (1) encounter is a face-to-face visit with a MD/DO and other encounter(s) is/are face-to-face visit(s) with an OD, DPM, or non-behavioral health APRN for the same, related, or unrelated condition(s).

II.  The patient makes visits for different types of services, specifically, dental or behavioral health. Medicaid shall pay for a maximum of one visit per day for each of these services in addition to one medical visit.

SOURCE: HI Medicaid Provider Manual (FQHC) (March 2016), p. 8-9. (Accessed Oct. 2022).

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Idaho

Last updated 08/22/2022

All contact with providers for the same type of encounter …

All contact with providers for the same type of encounter counts as a single encounter. An encounter with more than one health professional, or multiple contacts with the same professional, in the same day, and all incidental services constitutes a single encounter. If a participant has a visit with a healthcare professional that qualifies as an encounter, any group education or activities provided on the same day are included in the encounter. Missed appointments, visits to pick up medication, or incidental services on the day of the encounter are not considered a separate encounter. Encounters are limited to three per day for FQHCs. An exception is allowed for an additional encounter of the same type when a participant, subsequent to the first encounter, suffers an illness or injury that requires additional diagnosis and treatment and is supported by documentation. Qualifying additional encounters should be billed with Modifier 59.

SOURCE: ID Medicaid Provider Handbook: IHS, FQHC, and RHC Services (June 14, 2022)., p. 16.  (Accessed Aug. 2022).

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Illinois

Last updated 11/18/2022

Only one medical encounter per patient per day can be …

Indiana

Last updated 10/30/2022

The IHCP allows reimbursement for only one medical encounter code …

The IHCP allows reimbursement for only one medical encounter code (T1015) per IHCP member, per billing provider, per day – unless the primary diagnosis code differs for each additional encounter. Multiple T1015 encounter claims from an FQHC or RHC for a member on the same date of service that do not include a different primary diagnosis code are denied for EOB 5000 or 5001 – This is a duplicate of another claim.

If a member visits an office twice on the same day with two different diagnoses, a second claim can be submitted for the second visit, using a separate professional claim form or electronic claim submission. However, this policy does not allow a provider to bill multiple claims for a single visit with multiple diagnoses by separating the diagnoses on different claims.

When two valid practitioners, such as a physician and a psychologist, see the same patient in the same day, the principal diagnoses should not be the same.

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

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Iowa

Last updated 10/25/2022

Only one face-to-face encounter between a member and the center

Only one face-to-face encounter between a member and the center health professional can be billed per day, even though the member may encounter the professional more than once or may encounter more than one professional.

Any necessary services should be provided during one encounter whenever possible. When there is a need for services to be unbundled that would normally be provided during one encounter medical necessity must be documented and maintained in the record.

An exception to this is when the member suffers illness or injury requiring additional diagnosis or treatment after the first encounter on a particular day. In that situation, another encounter is reimbursable. Refer those claims to IME Provider Services for special handling.

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Kansas

Last updated 08/24/2022

Encounters with more than one health professional, or multiple encounters …

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 the patient suffers illness or injury subsequent to the first visit on the same day requiring additional diagnosis and treatment which are different from the first visit, the second encounter qualifies as an additional visit.

Subsequent visit on the same day must be medically necessary and include documentation of why the subsequent service could not have been provided during the initial encounter.

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

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Kentucky

Last updated 10/31/2022

No reference found

No reference found

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Louisiana

Last updated 11/08/2022

Multiple medical and/or behavioral health encounters, however, with more than …

Multiple medical and/or behavioral health encounters, however, 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. When the beneficiary suffers illness or injury requiring additional diagnosis or treatment unrelated to the initial encounter visit an additional medical and/or behavioral health encounter may be billed.

Multiple dental 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.

Only one medical encounter (inclusive DSMT encounters) per day per beneficiary, one behavioral health encounter per day per beneficiary, and one dental encounter per day per beneficiary may be billed except in cases in which the beneficiary, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment. Services shall not be arbitrarily delayed or split in order to bill additional encounters.

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).

An FQHC provider can be reimbursed for only one medical, one behavioral health, and one dental encounter per day. Core service encounters with more than one health professional, and multiple encounters with the same health profession, that take place on the same date of service, at a single location, constitute a single visit, and are limited to one encounter per day except when one of the following conditions exists:

  1. After the first encounter, the beneficiary suffers illness or injury requiring additional diagnosis or treatment; and
  2. The beneficiary has a medical visit or dental visit on the same day. Behavioral health benefits are subject to the requirements outlined in Section 22:1 Covered Services, of this provider manual chapter.

SOURCE: LA Dept. of Health and Hospitals, Federally Qualified Health Centers Provider Manual, Chapter 22, Sec. 22.4, pg. 30-31, (As replaced on Mar. 10, 2022) (Accessed Nov. 2022).

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Maine

Last updated 10/18/2022

Reimbursement is generally limited to one core service visit, and/or …

Reimbursement is generally limited to one core service visit, and/or one ambulatory service visit per day. Reimbursement for a second core visit is also covered if the member has both an encounter with a physician, physician assistant, advanced nurse practitioner or visiting nurse, and in addition to that encounter, is seen on the same day by a licensed clinical psychologist, clinical social worker, clinical professional counselor or a clinical nurse specialist licensed as an advanced practice clinical nurse specialist. An additional visit of any other kind will only be reimbursed for unforeseen circumstances as documented in the member’s record. The goal remains to treat the whole individual during one visit.

SOURCE: MaineCare Benefits Manual, Federally Qualified Health Centers, 10-144 Ch. 101, Sec. 31, pg. 9. (Accessed Oct. 2022).

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Maryland

Last updated 11/22/2022

FQHCs and RHCs may be reimbursed for multiple encounters per …

FQHCs and RHCs may be reimbursed for multiple encounters per day, for each Medicaid participant, by billing one encounter for each of the following services provided: somatic services, mental health services, substance use disorder (SUD) services, and dental services. Behavioral health services provided via telehealth must be submitted using one of the appropriate procedure codes.

SOURCE: MD Medical Assistance Program PT 38-22. Claims and Encounter Submissions. March 21, 2022. (Accessed Nov. 2022).

“All-inclusive cost-per-visit rate” means the rate that is established for Federally Qualified Health Centers (FQHCs) which includes all services that are rendered to a participant on a given date of service.

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

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Massachusetts

Last updated 11/18/2022

The CHC may bill for a visit, a treatment, or …

The CHC may bill for a visit, a treatment, or a procedure, but may not bill for more than one of these services provided to the same member on the same date when the services are performed in the same location. This limitation does not apply to tobacco cessation counseling services provided by a physician or other qualified staff member under the supervision of a physician on the same day as a visit. See regulations for additional instructions for specific types of services (such as obstetrics, acupuncture, audiology, etc.)

SOURCE: MA 130 CMR 405.421, (Accessed Nov. 2022).

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Michigan

Last updated 11/22/2022

An FQHC may be credited with one encounter for each …

An FQHC may be credited with one encounter for each different type of visit provided to a beneficiary during a single day, regardless of the number of services provided at the visit. A maximum of three encounters are allowed per beneficiary per day (one medical, one dental, and one behavioral health). In cases where the beneficiary, after the first visit, suffers illness or injury requiring additional diagnosis or treatment, these visits may be classified as two encounters.

SOURCE: Dept. of Health and Human Services Medicaid Provider Manual, p. 741, Oct. 1, 2022 (Accessed Nov. 2022). 

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Minnesota

Last updated 10/24/2022

MHCP covers one medical and one dental encounter per day …

MHCP covers one medical and one dental encounter per day for federally funded MA members. A medical encounter and a dental encounter can occur on the same day. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment.

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 limits reimbursement to a Federally Qualified …

The Division of Medicaid limits reimbursement to a Federally Qualified Health Center (FQHC) to no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different type of visit, as the Division of Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the following visit: 1. Medical, 2. Mental health, 3. Dental, or 4. Vision

Visits with more than one (1) health professional and multiple visits with the same health professional that take place on the same day at a single location constitute a single encounter, except when the beneficiary: 1. Suffers an illness or injury subsequent to the first visit that requires additional diagnosis or treatment on the same day, or 2. Has multiple visit types on the same day.

The Division of Medicaid reimburses no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different provider type, as the Division of Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the provider types listed in Miss. Admin. Code, Title 23, Part 211, Rule 1.2.A. except if the beneficiary experiences an illness or injury requiring additional diagnosis or treatment subsequent to the first encounter. Services provided by a nurse practitioner (NP) or physician assistant (PA) are reimbursed the full PPS rate.

SOURCE: MS Admin. Code Title 23, Part 211, Rule. 1.3 & 1.5. (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

Reimbursement is available for one encounter per day per eligible …

Reimbursement is available for one encounter per day per eligible member unless it is necessary for the member:

  • to be seen by different health professionals with different specialties; or
  • to be seen multiple times per day due to unrelated diagnoses.

Encounters with the same primary diagnosis are not considered separately billable visits, regardless of the health professional providing the service.

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

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Nebraska

Last updated 11/18/2022

Encounters with more than one health professional and multiple encounters …

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).

Recipient encounters with more than one health professional, or multiple encounters with the same health professional, which take place on the same day for the same diagnosis or treatment, shall be counted as one visit.

RHCs and FQHCs shall bill for only one visit per recipient per day, except for cases in which the patient, subsequent to the first visit, suffers an illness or injury requiring additional diagnosis and treatment.

SOURCE: Administrative Rules Part HeW 537.08 Rural Health Clinics/ Federally Qualified Health Centers, (Accessed Nov. 2022).

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New Jersey

Last updated 09/06/2022

NJ FamilyCare will not reimburse a FQHC for two physical …

NJ FamilyCare will not reimburse a FQHC for two physical health primary diagnoses on the same day regardless if the services were provided by one or more than one core providers.

SOURCE: NJ Dept. of Human Services, Division of Medical Assistance & Health Services Outpatient Facility Behavioral Health Integration Billing FAQs. (Accessed Sept. 2022).

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.

  • Normally, only one medical encounter is covered per beneficiary, per day. More than one medical encounter is covered, however, when the beneficiary is seen by more than one licensed practitioner for the prevention, treatment or diagnosis of different injuries or illnesses, and practitioners of appropriate different specialties are involved.
  • More than one medical encounter is also allowed if a beneficiary leaves the centerafter having been seen by a practitioner, then returns to the center and is seen by another practitioner on the same day.
  • More than two medical encounters during a week for a beneficiary require clear documentation in the beneficiary’s medical record demonstrating the medical necessity of the encounter(s).
  • Interpretation of results of tests or procedures not requiring face-to-face contact between a beneficiary and a practitioner, and referrals to specialists, do not constitute a medical encounter.

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

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New Mexico

Last updated 10/28/2022

Encounters with more than one health professional and multiple encounters …

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

Only one threshold visit per patient per day is allowed …

Only one threshold visit per patient per day is allowed for reimbursement purposes, except for transfusion services to hemophiliacs, in which case each transfusion visit constitutes an allowable threshold visit. The visit is all-inclusive as it includes all of the services medically necessary and rendered on that date.

This policy does not apply to those services for which rates of payment have been established for each procedure, such as dialysis and freestanding ambulatory surgery.

When a Medicaid patient receives treatment(s) during a threshold clinic visit that cannot be completed due to administrative or scheduling problems, the Article 28 facility may not bill additional clinic visits for the completion of the service. For example, the completion of clinical laboratory test, blood draws or X-rays that are scheduled subsequent to the initial clinic visit do not qualify for reimbursement unless the patient is also seen for purposes of discussing the findings and for definitive treatment planning.

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

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North Carolina

Last updated 11/03/2022

Core service encounters with more than one health professional, and …

Core service encounters with more than one health professional, and multiple encounters with the same health professional, that take place on the same date of service and at a single location, constitute a single visit and are limited to one encounter per day, except when one of the following conditions exists:

  • After the first encounter, the beneficiary appears or presents with or suffers illness or injury requiring additional diagnosis or treatment; or
  • The beneficiary has a medical visit and an “other health” visit, such as a behavioral health visit. Core service visits for behavioral health are subject to the requirements and limitations specified in 42 CFR 405.2450 and 405.2452.

Note: Service is limited to a maximum of three encounters per day when the conditions of the above paragraphs are met. Written documentation shall be provided to justify more than three core visits billed on the same date of service.

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, Dec. 1, 2020. (Accessed Nov. 2022).

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North Dakota

Last updated 11/08/2022

Face-to-face services with more than one health professional and/or multiple …

Face-to-face services with more than one health professional and/or multiple services with the same health professionals on the same day and at a single location constitute a single encounter, except when one of the following conditions exist:

  • After the first encounter, the member suffers an illness or injury requiring additional diagnosis or treatment;
  • The member receives more than one type of service: medical, behavioral health, or dental.

Medical nutritional therapy or a diabetes self-management training provided on the same day as a medical encounter is not eligible for a separate encounter. If medical nutritional therapy or diabetes self-management training are the only medical service provided, a medical encounter may be claimed.

See the Telemedicine chapter for additional information on services rendered via telemedicine.

SOURCE: ND Medicaid General Information Provider Manual, Oct. 2022, pg. 50, (Accessed Nov. 2022).  

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Ohio

Last updated 09/07/2022

Multiple encounters with one health professional or encounters with multiple …

Multiple encounters with one health professional or encounters with multiple health professionals constitute a single visit if all of the following conditions are satisfied:

  • All encounters take place on the same day;
  • All contact involves a single PPS service; and
  • The service rendered is for a single purpose, illness, injury, condition, or complaint.
  • Multiple encounters constitute separate visits if one of the following conditions is satisfied:
  • The encounters involve different PPS services; or
  • The services rendered are for different purposes, illnesses, injuries, conditions, or complaints or for additional diagnosis and treatment.

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

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Oklahoma

Last updated 09/05/2022

An FQHC may bill for one (1) medically necessary encounter …

An FQHC may bill for one (1) medically necessary encounter per twenty-four (24) hour period when the appropriate modifier is applied. Medical review will be required for additional visits for children. For information about multiple encounters, refer to OAC 317:30-5-664.4. Payment is limited to four (4) visits per member per month for adults.

SOURCE: OK Admin. Rule 317:30-5-664.3. (Accessed Sept. 2022).

An FQHC may bill for more than one (1) medically necessary encounter per 24-hour period under certain conditions when the appropriate modifier is applied.

  • It is intended that multiple medically necessary encounters will occur on an infrequent basis.
  • An FQHC may not develop FQHC procedures that routinely involve multiple encounters for a single date of service, unless medical necessity warrants multiple encounters.
  • Each service must have distinctly different diagnoses in order to meet the criteria for multiple encounters. For example, a medical visit and a dental visit on the same day are considered different services with distinctly different diagnoses.
  • Similar services, even when provided by two (2) different health care practitioners, are not considered multiple encounters.
  • Encounters with more than one (1) FQHC practitioner on the same day, regardless of the length or complexity of the visit, would constitute a single visit. An exception is when the patient has either or both of these:
  • An illness or injury requiring additional diagnosis or treatment subsequent to the first encounter; and/or
  • A qualified medical visit, a qualified mental health and/or dental visit on the same day.

SOURCE: OK Admin. Rule 317:30-5-664.4. (Accessed Sept. 2022).

Rural Health Centers (RHC) and Federally Qualified Health Centers (FQHC) Monthly Visit Limitation Revisions

The revisions allow a SoonerCare Choice member who has chosen an RHC/FQHC as their Patient-Centered Medical Home (PCMH)/Primary Care Provider (PCP) to exceed the four-visit monthly limitation. (Reference OAC 317:30-5-356, 317:30-5-361, and 317:30- 5-664.3).

SOURCE: OK Health Care Authority, OHCA 2022-13. (Accessed Sept. 2022).

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Oregon

Last updated 11/10/2022

The following services may be considered as multiple encounters when …

The following services may be considered as multiple encounters when two or more service encounters are provided on the same date of service with distinctly different diagnoses (see OAR 410-147-0120 and individual program rules listed below for specific service requirements and limitations):

  • Medical section (3) of this rule and OAR chapter 410, division 130);
  • Dental (OAR 410-147-0125, and OAR chapter 410, division 123);
  • Addiction and Alcohol and Chemical Dependency — If a client is also seen for a medical office visit and receives an addiction diagnosis, then the client contacts area single encounter (Refer to AMH’s OARs);
  • Ophthalmologic services — fitting and dispensing of eyeglasses are included in the encounter when the practitioner performs a vision examination. (OAR chapter 410, division 140);
  • Maternity Case Management MCM (OAR 410-147-0200);
  • Physical or occupational therapy (PT/OT) — If this service is also performed on the same date of service as the medical encounter that determined the need for PT/OT (initial referral), then it is considered a single encounter (OAR chapter 410, division 131);
  • Immunizations — if no other medical office visit occurs on the same date of service; and
  • Tobacco cessation — if no other medical, dental, mental health or addiction service encounter occurs on the same date of service (refer to OAR 410-130-0190).

A mental health encounter and an addiction and alcohol and chemical dependency encounter provided to the same client on the same date of service will only count as multiple encounters when provided by two separate health professionals and each encounter has a distinctly different diagnosis.

Similar services, even when provided by two different health care practitioners, are not considered multiple encounters.

Clinics may not “unbundle” services that are normally rendered during a single visit for the purpose of generating multiple encounters:

  • Clinics are prohibited from asking the patient to make repeated or multiple visits to complete what is considered a reasonable and typical office visit, unless it is medically necessary to do so;
  • Medical necessity must be clearly documented in the patient’s record.

SOURCE: OR OAR 410-147-0140, 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

FQHCs/RHCs may bill for more than one encounter (such as …

FQHCs/RHCs may bill for more than one encounter (such as a medical encounter, and a dental encounter) for the same patient on the same day. Additional other health encounters may be billed with the applicable type of service; however, medical necessity for the billing of such multiple encounters on the same day must be fully documented (including the time individually spent with the patient during each encounter) and justified in the patient’s record. Medical necessity for multiple daily encounters is verified by periodic site audit, and must meet the federal standard mandated at 42 CFR §405.2463.

The allowance of billing for multiple types of encounters in a single day must not interfere with the recipient’s freedom in choosing a provider. A recipient may obtain medical, dental or other health services from any institution, agency, pharmacy, person, or organization that is approved by the Department to provide them. Therefore, the FQHC/RHC shall not make any direct or indirect referral arrangements between practitioners and other providers of medical services or supplies but may suggest the services of another clinic provider or practitioner; automatic referrals between providers continue to be prohibited (Chapter 1101.51).

SOURCE: PA PROMISe Provider Handbook pg. 11, 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

Only one encounter code is allowed per day, with the …

Only one encounter code is allowed per day, with the exception of the psychiatry and counseling encounter, which can be billed in addition to another encounter on the same day. FQHC services are covered when furnished to patients at the center, in a SNF, or at the client’s place of residence. Services provided to hospital patients, including ER services, are not considered FQHC services.

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

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).

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South Dakota

Last updated 11/10/2022

Encounters with more than one health professional and multiple encounters …

Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day constitute a single visit. Payment is limited to two visits a day. A second visit is payable only under the following conditions:

  • After the first visit, the patient suffers illness or injury which requires additional diagnosis or treatment.
  • One of the services is a complete comprehensive EPSDT screening with the components required in 67:16:11:04.
  • One of the visits is for behavioral health services covered under the provisions of 67:16:41 or 67:16:48.
  • One of the visits is for dental services provided under the provisions of 67:16:06.

SOURCE: SD Medicaid Billing and Policy Manual, FQHC and RHC Services, June. 2022, pg. 7 (Accessed Nov. 2022).

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Tennessee

Last updated 09/04/2022

No reference found

No reference found

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Texas

Last updated 09/07/2022

Encounters with more than one health professional and multiple encounters …

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

  • After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
  • The FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

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

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Utah

Last updated 08/23/2022

Reporting encounters for RHCs and FQHCs is limited to one

Reporting encounters for RHCs and FQHCs is limited to one encounter per day per patient. Encounters with more than one health professional or multiple visits with the same health professional on the same day constitute a single visit. The provider may bill up to, but not exceeding, the established encounter rate.

SOURCE: UT Division of Medicaid and Health Financing. Utah Medicaid Provider Manual, Rural Health Clinics and Federally Qualified Health Centers Services, Oct. 2021, pg. 5, (Accessed Aug. 2022).

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 RHCs and FQHCs that are authorized to bill under the reasonable cost system, encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the patient –

  • Suffers an illness or injury subsequent to the first visit that requires additional diagnosis or treatment on the same day;
  • Has a medical visit and a mental health visit on the same day; or
  • Has an initial preventive physical exam visit and a separate medical or mental health visit on the same day.

For RHCs and FQHCs that are authorized to bill under the reasonable cost system, Medicare pays RHCs and FQHCs for more than 1 visit per day when the conditions in paragraph (c)(1) of this section are met.

For FQHCs that are authorized to bill under the reasonable cost system, Medicare pays for more than 1 visit per day when a DSMT or MNT visit is furnished on the same day as a visit described in paragraph (c)(1) of this section are met.

For FQHCs billing under the PPS, and grandfathered tribal FQHCs that are authorized to bill as a FQHC at the outpatient per visit rate for Medicare as set annually by the Indian Health Service –

  • Suffers an illness or injury subsequent to the first visit that requires additional diagnosis or treatment on the same day; or
  • Has a medical visit and a mental health visit on the same day.

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

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Vermont

Last updated 10/27/2022

Face-to-face visits with more than one provider and multiple visits …

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.

If an FQHC/RHC provides one or more services on the same day to a Vermont Medicaid member with insurance other than Medicare, the visit should first be billed to the other insurer using the appropriate CPT code(s). The facility may bill Vermont Medicaid for the balance between the other insurance payment and the facility’s encounter rate using T1015 as the encounter code. (Refer to the instructions in Section 29 of CMS-1500 form.)

See supplement for examples of two separate encounters on the same day.

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

Each individual provider is limited to one type of encounter …

Each individual provider is limited to one type of encounter per day for each client, regardless of the services provided except in the following circumstances:

  • The client needs to be seen by different practitioners with different specialties.
  • The client needs to be seen multiple times due to unrelated diagnoses.

Each encounter must be billed on a separate claim form. On each claim, to indicate that it is a separate encounter, enter “unrelated diagnosis,” the time of both visits in the Claim Note section, and the appropriate modifier for the service provided.

When billing two different claims for the same date of service, a modifier must be entered on at least one of the claims. The same modifier cannot be used on the first and second claim. HCA must fully process the first claim before the provider submits the second.

Documentation for all encounters must be kept in the client’s file

SOURCE: WA HCA Provider Guide, Federally Qualified Health Centers, p. 9, 20, 63 (Aug. 2022), (Accessed Aug. 2022).

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West Virginia

Last updated 09/02/2022

An FQHC may bill for up to three separate encounters …

An FQHC may bill for up to three separate encounters per member occurring in one day:

  1. One medical encounter;
  2. One behavioral health encounter; and
  3. One dental encounter

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

  • After the first medical encounter, the patient suffers from an illness or injury requiring an additional diagnosis or treatment; or
  • The patient has a behavioral health visit with an LP, LICSW, LCSW, LGSW under the supervision of the LICSW or LCSW, LPC; or
  • The patient has a dental visit with the dentist. An Initial Preventive Physical Examination (IPPE) or an Annual Wellness Visit (AWV) is considered an FQHC or RHC encounter. However, if it is provided in conjunction with another service, it may not be billed separately.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual. Chapter 522.8 Federally Qualified Health Center and Rural Health Clinic Svcs. P. 6. (July 1, 2019). (Accessed Sept. 2022).

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Wisconsin

Last updated 11/21/2022

ForwardHealth reimburses a CHC a maximum of one PPS rate …

ForwardHealth reimburses a CHC a maximum of one PPS rate per encounter type, per member, per DOS, unless the member, subsequent to the first encounter, suffers an illness or injury that requires additional diagnosis or treatment on the same day. A subsequent encounter is a unique situation that cannot be planned or anticipated. For example, a member sees their provider in the morning for a medical condition and later in the day has a fall and returns to the CHC. Subsequent encounters can be medical, dental, or behavioral health when the encounter satisfies the subsequent encounter requirements.

When a CHC member receives services of the same encounter type from more than one of the CHC’s locations (for example, the main clinic, an off-site clinic, and/or a contracted facility) on a single day, the CHC will be reimbursed for only one encounter type, per DOS, unless the additional encounter qualifies as a subsequent encounter.

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

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Wyoming

Last updated 10/20/2022

Reimbursement is available for one encounter per day per eligible …

Reimbursement is available for one encounter per day per eligible Member unless it is necessary for the Member:

  • To be seen by different health professionals with different specialties; or
  • To be seen multiple times per day due to unrelated diagnoses
    • When a Member is seen by providers of the same specialty within the same visit, services rendered are reimbursable as one face-to-face encounter

Multiple encounters within the FQHC, on the same day, with different practitioners are still considered one (1) encounter UNLESS the Member suffers illness or injury requiring treatment unrelated to the first encounter or if the Members have both a medical visit and other health visit, as defined above.

SOURCE: WY Dept. of Health, Medicaid Institutional Provider Manual, pgs. 238 & 241, (Sept. 30, 2022). (Accessed Oct. 2022).

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Federally Qualified Health Center (FQHC)

Same Day Encounters

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