Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)

Medicare will provide supplemental payments to FQHCs that contract with MAOs to cover the difference, between the payment received from the MAO and the payment to which the FQHC would be entitled under FQHC PPS.

An FQHC is only eligible to receive this supplemental payment when FQHC services are provided during a face-to-face encounter. FQHC’s seeking supplemental payments must submit copies of their contracts under each MA plan.

New Billing Instructions for FQHC PPS Providers

  • Payment code with facility’s payment code charge to represent the billable encounter
  • Qualifying visit HCPCS code must be reported with actual line-item charges for services provided
  • All services must be billed with revenue code 0519 with one (1) unit (including any incident to services)
  • MAO plan interim supplemental rate is no longer reflected on claim line
  • All other billing guidelines apply

Claim Example: MAO Plan Supplemental Payment Claim for Established FQHC Patient

Established MAO patient comes to the FQHC for a medical encounter. Claim will be reported as follows:

  • Payment code G0467 (medical encounter for established FQHC patient) with one (1) unit, Total Charges reflecting the facility’s payment code charge for G0467 ($150)
  • Qualifying visit HCPCS code with one (1) unit, Total Charges reflecting actual line-item costs for service ($120)
  • All lines report revenue code 0519
  • 0001 Totals line calculated appropriately
42 Rev Cd 43 Description 44 HCPCS 45 Serv Date 46 Serv Units 47 Total Charges
0519 FQHC visit, estab pt G0467 100114 1 $150
0519 Office/outpatient visit estab pt 99212 100114 1 $120
0001 Total       $270

Payment will be the difference between the MAO plan’s contracted payment rate and what the reimbursement would be under FQHC PPS (the lesser of the adjusted PPS rate and the facility’s payment code charge for the reported payment code).

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