FQHC, RHC and THC billing
Medicare
For Medicare RHC, FQHC and THC claims, Priority Health follows Centers for Medicare and Medicaid Services (CMS) guidelines.
Medicaid
Per the State of Michigan (SOM), reimbursement rates and what is/is not covered for each health center type (FQHC, RHC, THC) are the result of negotiations between the respective associations and the SOM. This explains why some services are covered for one provider type and not for others. Priority Health has had multiple conversations with the SOM and confirmed our system setup, processing, and reimbursement is correctly meeting the intent of the August 1, 2017 changes.
General FQHC/RHC/THC billing guidelines
Submit claims on an institutional claim form (837I or UB).
Priority Health reimburses the suggested managed care rates for the respective dates of service when Clinic-PPS visit codes are billed with a valid clinic qualifying visit.
J-codes:
- Priority Health provides additional reimbursement for J-codes listed on the FQHC fee schedule. These are paid off the fee schedule. J-codes may be billed with a Clinic-PPS visit code and a clinic qualifying visit.
- RHCs and THCs did not negotiate the reimbursement of any J-codes, so those reimbursed at $0.00 for those entity types.
Priority Health will not use the fee schedule to individually reimburse any other codes. Any codes not individually reimbursed are reimbursed at $0.00 with denial code Q11-No Compensation-Reporting Only./p>
Rate letters: Priority Health does not reimburse providers based on the rate listed on provider rate letters. Per the SOM, Priority Health pays only the suggested managed care rates. The SOM will settle the difference between the suggested managed care rates and the rate letter during the quarterly/annual reconciliation process.
Quarterly/annual reconciliation: During this process, SOM settles with the health center on those services we do not consider for reimbursement or those where the state pays a higher rate.
Multiple visits/OB packages billing
Submit claims on an institutional claim form (837I or UB).
Clinic-PPS Visit Codes will reimburse at the provider’s PPS rate. RHC Clinic-PPS Visit Codes must be billed with a Qualifying Visit to receive payment.
Multiple Visit Codes will be reimbursed at the providers' PPS rate multiplied by the appropriate Qualifying Visit count.
Behavioral health billing
Submit claims on an institutional claim form(837I or UB).
Billing requirements and reimbursement rates are the same for behavioral health services as they are for any other services provided by an FQHC/RHC/THC. However, if multiple medical services are provided on the same day, it is appropriate for behavioral health claims to contain two Clinic-PPS visit codes and two clinic qualifying visits. In these instances, Priority Health reimburses the suggested managed care rate for each set of qualifying criteria.
Routine vision billing
Submit claims on an institutional claim form (837I or UB).
Priority Health pays the suggested managed care rates when routine vision services are billed with the appropriate Clinic-PPS visit code and clinic qualifying visit.
MIHP billing
Submit claims on a professional claim form (837P or 1500).
Priority Health reimburses those services at the MIHP-established rates. Providers are not required to have a separate NPI for billing MIHP services.