Wash. Admin. Code § 182-548-1450 - Federally qualified health centers-General payment information
(1) The agency
limits FQHC encounter rate reimbursement to one per client, per day except in
the following circumstances:
(a) There is a
subsequent visit in the same cost center that requires separate evaluation and
treatment on the same day for unrelated diagnoses; or
(b) There are separate visits in different
types of cost centers that occur with different health care professionals. (For
example, a client with a separate medical and dental visit on the same
day.)
(2) All services
provided within the same cost center performed on the same day must be included
in the same encounter, except for in the circumstance outlined in subsection
(1)(a) of this section.
(3)
Services and supplies incidental to an encounter are included in the encounter
rate payment and must be billed on the same claim.
(4) FQHCs must provide services in a single
encounter that are typically rendered in a single visit based on clinical
guidance and standards of care.
(a) FQHCs
must not split services into multiple encounters unless there is clinical
justification. (For example, fluoride treatment must be provided on the same
day as an encounter-eligible service.)
(b) Clinical justification must be based on
medical necessity and documented in the client's record.
(5) Services provided in an FQHC that are not
encounter-eligible are paid on a fee-for-service basis according to agency
rules, billing guides and fee schedules.
(6) Managed care organization (MCO)
contracted services provided in an FQHC for clients enrolled in an MCO are paid
for by the MCO.
(7) For clients
enrolled with an MCO, the agency pays each FQHC a supplemental payment in
addition to the amounts paid by the MCO. The supplemental payments, called
enhancements, are paid in amounts necessary to ensure compliance with
42 U.S.C.
1396a(bb)(5)(A).
(a) The FQHCs receive an enhancement payment
each month for each managed care client assigned to them by an MCO.
(b) To ensure that the appropriate amounts
are paid to each FQHC, the agency performs an annual reconciliation of the
enhancement payments.
(i) For each FQHC, the
agency compares the amount paid in enhancement payments to the amount
determined by the following formula:
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(ii) If the
agency determines that the FQHC was overpaid, the agency recoups the
appropriate amount. If the agency determines that the FQHC was underpaid, the
agency pays the difference.
(iii)
The agency may prospectively adjust the FQHC's monthly enhancement payments if
the agency determines the FQHC has been overpaid or underpaid in the annual
reconciliation.
(A) The agency uses the FQHC's
most current reconciliation data, and any supplemental information provided by
the FQHC to determine if any adjustment to the enhancement rate is
necessary.
(B) If the agency
determines a prospective adjustment to enhancement payments is necessary, the
agency notifies the FQHC in writing at least 30 calendar days prior to the
enhancement payment adjustment.
(8) The agency pays the encounter rate and
the enhancement payments with respect to services provided to
encounter-eligible clients. Services provided to clients who are enrolled in
medical programs that are paid only in state funds are not encounter-eligible;
these claims are paid on a fee-for-service basis regardless of the type of
service performed.
Notes
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