Modification to Federally Qualified Healthcare Center (FQHC) and Rural Health Center (RHC) enrollment and claims submission criteria.

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Effective February 1, 2013 the South Carolina Department of Health and Human Services (SCDHHS) will implement the following changes to the Federally Qualified Healthcare Center (FQHC) and Rural Health Center (RHC) enrollment and claims submission criteria. These changes are being made in accordance with the implementation of new Medicaid provider enrollment and screening regulations, as published by the Centers for Medicare and Medicaid Services (CMS).  These regulations have been developed under standards established by the Affordable Care Act.

To be in compliance with the enrollment criteria, FQHCs and RHCs will be required to enroll all clinical staff providing/rendering service to SC Medicaid beneficiaries.  Clinical staff includes: Physicians, Advanced Practice Registered Nurse (APRN), Physician Assistant, Licensed Independent Social Worker - Clinical Practice (LISW-CP), PhD. Psychologist, and Certified Nurse Midwife, Licensed Master’s Social Workers (LMSW), Licensed Professional Counselor (LPC), and Licensed Marriage and Family Therapist (LMFT).  Clinical staff will then need to be linked to each individual FQHC and RHC group number to meet claims submission criteria.

To assist with identifying individual clinical staff that need to be enrolled and linked to existing group numbers, SCDHHS has attached a form that you must complete and fax to Provider Enrollment at (803) 870-9022 by January 15, 2013.  A separate form will be needed for each FQHC and RHC group number.

Provider Enrollment will help identify all individual providers currently enrolled with Medicaid and use the form to link these providers to the group.  If a provider is not currently enrolled, the FQHC or RHC facility will be notified and provided an enrollment package for the provider to complete.

The National Provider Identifier (NPI) of the referring and rendering provider must be included on the Medicaid claim form for payment.  The referring provider is the individual who directed the patient for care.  The rendering provider is the individual who provided

care to the patient.  For hard copy and electronic claim submission, providers can reference the following guidelines:

 

 

Claim Form

Field Number

Field Name

Special Note

CMS-1500 (08/05)

17

Name of Referring Provider or Other Source

Enter the name of Referring or Ordering Provider

 

17B

NPI

Enter the NPI of Referring or Ordering Provider

CMS-1500

24J Shaded

Rendering Provider ID

Enter the rendering provider’s taxonomy code.

CMS-1500

24J Un-shaded

Rendering Provider ID

Enter the rendering provider’s NPI

837P

2310A

Referring Provider

Enter the NPI of Referring or Ordering Provider

837P

2310B

Rendering Provider’s Taxonomy

Enter the rendering provider’s taxonomy code

837P

2310B

Rendering Provider NPI

Enter the rendering provider’s NPI

 

Providers may refer to the South Carolina Companion Guides for additional information regarding placement of the referring NPI and Taxonomy on electronic claims.  The Companion Guides are located on the SCDHHS website at http://provider.scdhhs.gov.

In order to receive the correct clinic encounter reimbursement rate, it is imperative that the HCPCS code T1015 be in field 24E.

This bulletin affects the policy for Fee-For-Service (FFS) beneficiaries and those in the Medical Home Networks (MHNs).  For beneficiaries enrolled in a Managed Care Organization (MCO), please refer to the individual MCO plan regarding their services. The MCO plans will be notified of this change.

Please refer any questions regarding this bulletin to the SCDHHS Provider Service Center at 1-888-289-0709.  Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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