Or. Admin. Code § 410-147-0320 - Federally Qualified Health Center Rural Health Clinics Enrollment
(1) This rule
outlines the Division of Medical Assistance Programs (Division) enrollment
requirements for Federally Qualified Health Centers (FQHC) and Rural Health
Clinics (RHC) (Refer also to OARs
410-120-1260 and
407-120-0320, Provider
Enrollment).
(a) For outpatient health
programs or facilities operated by an American Indian tribe under the Indian
Self-Determination Act ( Public Law 93-638), providers should refer to the
program rules for American Indian/Alaska Native (AI/AN) Services, OAR chapter
410, division 146, for enrollment details;
(b) An FQHC or RHC that operates a retail
pharmacy; provides durable medical equipment, prosthetics, orthotics, and
supplies (DMEPOS); or provides targeted case management (TCM) services, must
enroll separately as a pharmacy, DMEPOS and/or TCM provider. For specific
information, refer to OAR chapter 410, division 121, Pharmaceutical; OAR
chapter 410, division 122, DMEPOS; and OAR chapter 410, division 138,
TCM.
(c) A county Community Mental
Health Program (CMHP) furnishing extended care services under contract with the
Oregon Health Authority Addictions and Mental Health Division (AMH) should
refer to AMH for licensure and reimbursement requirements.
(2) To enroll with the Division as an FQHC, a
health center must comply with one of the following:
(a) Receive Public Health Service (PHS) grant
funds under the authority of Section 330;
(b) Have received FQHC Look-Alike designation
from the Centers for Medicare and Medicaid Services (CMS), based on the
recommendation of the Health Resources and Services Administration
(HRSA)/Bureau of Primary Health Care (BPHC); or
(c) Be an Urban Indian Health Program (UIHP)
clinic (under Title V of the Indian Health Care Improvement Act, Public Law
94-437). In the Omnibus Reconciliation Act (OBRA) of 1993, Title V programs
were added to the list of specific programs automatically eligible for FQHC
designation.
(3)
Eligible FQHCs who want to enroll with the Division as an FQHC, and receive
reimbursement under the Prospective Payment System (PPS) encounter rate
methodology, must submit the following information:
(a) Completed Authority provider enrollment
forms with attachments as required in OARs
943-120-0300 through
0320;
(b) National Provider
Identifier (NPI) number and associated taxonomy code obtained for the FQHC with
the provider enrollment form (refer to OAR
943-120-0320);
(c) Completed Cost Statement (DMAP 3027):
(A) One each for medical, dental and mental
health (including addiction, alcohol and chemical dependency) (see also OAR
410-147-0360);
(B) One for each FQHC-designated site, unless
specifically exempted in writing by the Division to file a consolidated cost
report (see also OAR 410-147-0340 Federally Qualified
Health Centers (FQHC) and Rural Health Clinics (RHC)/provider
numbers);
(d) Completed
copy of the grant proposal submitted to HRSA/BPHC detailing the clinic's
service and geographic scope;
(e)
Copy of the HRSA Notice of Grant Award Authorization for Public Health Services
Funds under Section 330, or a copy of the letter from CMS designating the
facility as a "Look Alike" FQHC;
(f) A copy of the clinic's trial balance (see
OAR 410-147-0500, Total Encounters
for Cost Reports);
(g) Audited
financial statements (refer to OAR
410-120-1380 Compliance with
Federal and State Statutes, and Office of Management and Budget Circular A-133
entitled "Audits of States, Local Governments and Non-Profit
Organizations");
(h) Depreciation
schedules;
(i) Overhead cost
allocation schedule;
(j) A copy of
the clinic's AMH certification for a program of mental health services if
someone other than a licensed psychiatrist, licensed clinical psychologist,
licensed clinical social worker, psychiatric nurse practitioner, licensed
professional counselor or licensed marriage and family therapist is providing
mental health services;
(k) A copy
of the clinic's AMH letter or licensure of approval if providing Addiction,
Alcohol and Chemical Dependency services;
(l) A list of all Prepaid Health Plan (PHP)
contracts;
(m) A list including
names and NPI numbers of individual practitioners enrolled with the Division
and contracted with or employed by the FQHC; and
(n) A list including business names,
addresses and facility NPI numbers for all Division-enrolled clinics affiliated
or owned by the FQHC including any clinics that do not have FQHC
status.
(4) For
enrollment with the Division as an RHC, a clinic must:
(a) Be designated by CMS as an RHC.
(b) Maintain Medicare certification and be in
compliance with all Medicare requirements for certification.
(5) Eligible RHCs who want to
enroll with the Division as an RHC, and be eligible for payment under the
Prospective Payment System (PPS) encounter rate methodology, must submit the
following information:
(a) Completed the
Authority provider enrollment forms with attachments as required in OARs
943-120-0300 through
-0320;
(b) National Provider
Identifier (NPI) number and any associated taxonomy codes obtained for the RHC
with the provider enrollment form (refer to OAR
943-120-0320);
(c) Copy of Medicare's letter certifying the
clinic as an RHC;
(d) Medicare Cost
Report for RHC or completed Cost Statement(s) (DMAP 3027) (see OAR
410-147-0360). Complete a cost
statement for each RHC-designated site, unless specifically exempted in writing
by the Division to file a consolidated cost report (see OAR
410-147-0340):
(A) The Division will accept an uncertified
Medicare Cost Report;
(B) If the
clinic's Medicare Cost Report, provided to the Division, does not include all
covered Medicaid costs provided by the clinic, the clinic must submit
additional cost information. The Division will include these costs when
determining the PPS encounter rate;
(C) An RHC can submit the Cost Statement
(DMAP 3027) as a substitute to the Medicare Cost Report.
(e) A copy of the clinic's trial balance (see
OAR 410-147-0500, Total Encounters
for Cost Reports only if completing Cost Statement DMAP 3027);
(f) Audited financial statements (refer to
OAR 410-120-1380 Compliance with
Federal and State Statutes, and Office of Management and Budget Circular A-133
entitled "Audits of States, Local Governments and Non-Profit Organizations" if
completing Cost Statement DMAP 3027);
(g) Depreciation schedules (only if
completing Cost Statement DMAP 3027);
(h) Overhead cost allocation schedules (only
if completing Cost Statement DMAP 3027);
(i) A copy of the clinic's AMH certification
for a program of mental health services if someone other than a licensed
psychiatrist, licensed clinical psychologist, licensed clinical social worker,
psychiatric nurse practitioner, licensed professional counselor or licensed
marriage and family therapist is providing mental health services;
(j) A copy of the clinic's AMH letter or
licensure of approval if providing Addiction, Alcohol and Chemical Dependency
services;
(k) A list of all Prepaid
Health Plan (PHP) contracts;
(l) A
list including names and NPI numbers of individual practitioners enrolled with
the Division and contracted with or employed by the RHC; and
(m) A list including business names,
addresses and facility NPI numbers for all Division-enrolled clinics affiliated
or owned by the RHC including any clinics that do not have RHC
status.
(6) The FQHC/RHC
Program Manager, upon receipt of the required items as listed in Section (3) of
this rule for FQHCs and Section (5) of this rule for RHCs, will review all
documents for compliance with program rules, completeness and
accuracy.
(7) The Division
prohibits an established, enrolled FQHC or RHC that adds or opens a new clinic
site from submitting claims for services rendered at the new site under their
FQHC or RHC Division enrollment, and according to the PPS encounter rate, prior
to the Division's acknowledgment. An FQHC or RHC is required to immediately
submit to the attention of the FQHC/RHC Program Manager, Division:
(a) For FQHCs only, a copy of the recent HRSA
Notice of Grant Award including the new site under the main FQHC's
scope;
(b) For RHCs only, a copy of
Medicare's letter certifying the new clinic as an RHC;
(c) A recent list of all PHP contracts;
and
(d) A recent list of names and
NPI numbers for all individual practitioners enrolled with the Division and
contracted with or employed by the new FQHC or RHC site.
(8) If an established and enrolled RHC or
FQHC changes ownership, the new owner must submit:
(a) Cost Statement (DMAP 3027) or Medicare
Cost Report within 30 days from the date of change of ownership to have a new
PPS encounter rate calculated; or in writing, a letter advising adoption of the
PPS encounter rate calculated under the former ownership (see OAR
410-147-0360);
(b) Notice of a change in tax identification
number;
(c) A recent list of all
Prepaid Health Plan (PHP) contracts;
(d) A recent list of names and NPI numbers
for all individual practitioners enrolled with the Division and contracted with
or employed by the FQHC or RHC; and
(e) A recent list including business names,
addresses, NPI numbers and associated taxonomy codes for all Division-enrolled
clinics affiliated or owned by the FQHC or RHC including any clinics that do
not have FQHC or RHC status.
(9) FQHCs that are involved with a
sub-recipient must provide documentation. Sub-recipient contracts with an FQHC
must enroll as an FQHC and submit the same required documentation as outlined
under the enrollment sections of this rule.
Notes
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
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