Billing

Billing for Services Not Included in the FQHC Benefit

Certain services are not considered FQHC services because they are not included in the FQHC benefit. Items or services that are covered under Part B but are not FQHC covered services include, but are not limited to:

Ambulance Services

  • Ambulance services are separately payable only under Part B. More information is available on our website under Part B.

Body Braces

  • Includes leg, arm, back, and neck braces and their replacements.
  • Billing Instructions: FQHC bills supplies authorized for billing under DMEPOS in accordance with DMEPOS requirements. More information is available on our website under DME > Billing Support > Claim Submission Articles.

Durable Medical Equipment

  • Includes crutches, hospital beds, and wheelchairs used in the patient’s place of residence, whether rented or purchased.
  • Billing Instructions: FQHC bills supplies authorized for billing under DMEPOS in accordance with DMEPOS requirements More information is available on our website under DME > Billing Support > Claim Submission Articles.

Laboratory Services

  • Although FQHCs are required to furnish certain laboratory services, these services are not within the scope of the FQHC benefit. When clinics and centers separately bill laboratory services, the cost of associated space, equipment, supplies, facility overhead and personnel for these services must be adjusted out of the RHC or FQHC cost report. This does not include venipuncture, which is included in the AIR when furnished in the FQHC by an FQHC practitioner or furnished incident to an FQHC service.
  • Billing Instructions for Independent FQHC: laboratory services are billed to the Part B MAC on professional claims (CMS-1500 claim form or 837P) under the practitioner’s NPI.
  • Billing Instructions for Provider-Based FQHC: laboratory services are  billed to the Part A MAC using the base provider’s NPI with the applicable TOB.

Medicare-Excluded Services

Practitioner Services at Certain Other Medicare Facilities

  • Includes services furnished to inpatients or outpatients in a hospital (including CAHs), ambulatory surgical center, Medicare CORF, etc., or other facility whose requirements preclude FQHC services. Services furnished to patients in any type of hospital setting (inpatient, outpatient, or emergency department) are statutorily excluded from the FQHC benefit.
  • Billing Instructions: If appropriate, these services may be billed to the Part B MAC. More information is available on our website under Part B.
  • RHC and FQHC practitioners that are compensated by the FQHC for services furnished in other locations may not bill the Part B MAC for these services. If the RHC or FQHC includes the costs of these services on their cost report, the services may not be billed to the Part B MAC.
  • Services that are billed to the Part B MAC cannot be claimed on the FQHC cost report.

Prosthetic Devices

  • Includes one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens, cardiac pacemakers, cochlear implants, electrical continence aids, electrical nerve stimulators, and tracheostomy speaking valves.
  • Billing Instructions: FQHC bills supplies authorized for billing under DMEPOS in accordance with DMEPOS requirements. More information is available on our website under DME > Billing Support > Claim Submission Articles.

Technical Component of an FQHC Service

  • Includes diagnostic tests such as x-rays, EKGs, and certain preventive services authorized by Medicare statute or the NCD process: screening pap smears; prostate cancer screening; colorectal cancer screening tests, AAA screening; screening mammography; and bone mass measurements.
    Note: The professional component is an FQHC service if performed by an FQHC practitioner or furnished incident to an FQHC service.
  • Billing Instructions for Independent FQHC: technical component is billed to the Part B MAC on professional claims (Form CMS 1500 or 837P) under the practitioner’s NPI
  • Billing Instructions for Provider-Based FQHC: technical component is billed to the Part A MAC using the base provider’s NPI with the applicable TOB

Provider Actions

  • Share this information with billing staff.
  • Update policies to ensure appropriate billing and compliance with Medicare claim-submission guidelines.
  • Update systems to reflect billing instructions.