FQHC Reimbursement Under the North Carolina State Health Plan Federally Qualified Health Center Pricing Agreement

The following information applies to health care organizations that selected FQHC Reimbursement under the North Carolina State Health Plan Federally Qualified Health Center pricing agreement. As a reminder, the following rules apply:

• Provider must submit claims on a facility claim form (UB-04) using the FQHC taxonomy for a patient encounter and follow all CMS code-level billing requirements (e.g., include appropriate revenue codes and “G” codes). More information can be found on the CMS website.
• Specific Payment and Qualifying visit codes are required (if applicable) and must be valid combinations.  Specific Payment Codes for the Federally Qualified Health Center Prospective Payment System (FQHC PPS) can be found through the CMS website (PDF).
• Services deemed to be separately reimbursable by CMS, meaning services which can be billed outside of a patient encounter, should be billed on a HCFA-1500 form, and will be reimbursed in accordance with “Section 2 – Professional Services” of the North Carolina State Health Plan Network Master Reimbursement Exhibit. If these services are billed on a UB they will be denied.
• You are configured as a FQHC provider under your CPP agreement and should not be billing services on a Professional 1500 that are payable under the FQHC Prospective Payment System. Services billed on a Professional 1500 that are payable under the FQHC Prospective Payment System will be denied as of July 1, 2023.
• Avoid duplicate claim filing as it will result in a delay in claims processing and claim denial.
• To receive the FQHC encounter rate for Mental Health services, providers will need to bill the specific payment/qualifying visit codes with revenue code 0519 only. Billing Revenue Code 900 will result in claim denials.

The North Carolina State Health Plan Federally Qualified Health Center Pricing Policy (“FQHC Pricing Policy”) document was provided to you in reference to Section II of the FQHC Addendum to the NC State Health Plan Network Participation Agreement. The FQHC Pricing Policy outlines the pricing of services that are covered by the North Carolina State Health Plan and are deemed separately reimbursable for purposes of State Health Plan members but are not priced as separately reimbursable services under the Medicare FQHC Prospective Payment System. The FQHC Pricing Policy was effective July 1, 2021.