Reimbursement : Amounts

Prospective Payment System Reimbursement

For the purposes of this Online Handbook topic:

• A PPS rate applies to CHCs and Tribal FQHCs.
• An AIR applies to Tribal FQHCs only.

Rates and Reimbursement

Under PPS, ForwardHealth reimburses CHCs and Tribal FQHCs for an encounter rate which includes all direct and indirect services provided to a member during an encounter.

ForwardHealth will apply the PPS rate or AIR for the encounter type to a claim detail associated with HCPCS procedure code T1015. All other payable claim details for direct and indirect services on the claim associated with the encounter will process in a paid status with a $0 allowed amount.

ForwardHealth only reimburses Tribal FQHCs for covered services and does not reimburse providers for the cost of any Tribal FQHC activities and services that:

• Are not required by ForwardHealth.
• Are part of Tribal FQHC-related services included in state statute or administrative code.

Calculation of the Prospective Payment System Rate

ForwardHealth calculates a separate PPS rate for each CHC or Tribal FQHC per the Benefits Improvement and Protection Act of 2000.

At the end of each CHC or Tribal FQHC fiscal year, ForwardHealth adjusts the PPS rate using FQHC market basket in effect at the time, which replaced the MEI in 2017. In addition, ForwardHealth may adjust a CHC's or Tribal FQHC's PPS rate to account for changes in the CHC's or Tribal FQHC's scope of service.

Reimbursement Guidelines

ForwardHealth reimburses a CHC or Tribal FQHC a maximum of one PPS rate per encounter type, per member, per DOS unless the member suffers an illness or injury after the first encounter that requires additional diagnosis or treatment on the same day.

When a CHC or Tribal FQHC member receives services of the same encounter type in a single day at more than one CHC or Tribal FQHC location (for example, the main clinic, an off-site clinic, and/or a contracted facility), ForwardHealth will reimburse the CHC or Tribal FQHC for only one encounter type per DOS—unless the additional encounter qualifies as a subsequent encounter.

Reimbursement for Services Provided by a Pharmacist

If the billing provider is a CHC or Tribal FQHC and the rendering provider is the pharmacist, then the CHC or Tribal FQHC may bill for covered medical services provided by the CHC's or Tribal FQHC's pharmacist. However, because the pharmacist is providing medical services, the one payer per service per day rule still applies. Encounter counting logic for PPS rates applies when all conditions are met for qualified encounters.

Services "Carved-Out" of the PPS Rate

Physician-administered drugs, telehealth distant site services, and certain pharmacy services are "carved out" of (not included in) PPS and are reimbursed separately.

Pharmacy Services

Some CHCs and Tribal FQHCs provide pharmacy services and bill for them on a ForwardHealth compound or noncompound drug claim. A CHC or Tribal FQHC pharmacy provider must enroll as a separate Medicaid provider under the applicable pharmacy provider type and specialty. The pharmacy must have the same tax ID as the main service location of the associated CHC or Tribal FQHC.

If a Tribal FQHC adds pharmacy services to their practice, they may qualify for a change in scope that may increase their PPS rate.

Physician-Administered Drugs

Physician-administered drugs are drugs administered by a provider in an office setting. The Physician-Administered Drugs Resources page contains a list of procedure codes classified as physician-administered drugs that may be reimbursed in addition to the PPS rate for an encounter. These services are subject to change and must meet all applicable ForwardHealth program requirements, including medical necessity, PA, claims submission, prescription requirements, and documentation requirements.

Telehealth Services

Telehealth services include "originating site" services and/or "distant site" services.

• Originating site services are not eligible for PPS.
• Distance site services are counted as encounters and must meet PPS rates guidelines.

CHC or Tribal FQHC costs associated with telehealth or teledentistry services may be reported for change in scope adjustment consideration; therefore, telehealth and teledentistry service costs may be used for future rate setting purposes.