CMS Pub. 100-04, ch. 12, § 80.2

B3-2260-2260.3

Payment may be made under Part B for the medical and other health services furnished by a

qualified rural health clinic (RHC) and Federally qualified health centers (FQHCs). The

covered services RHCs/FQHCs may offer are divided into two basic groups: RHC/FQHC

services (defined below) and other medical and other health services covered under Part B.

Items and services which meet the definition of RHC services or FQHC services are

reimbursed either by designated RHC intermediaries, or a national FQHC FI in the case of

independent RHCs/FQHCs, or by the provider’s A/B MAC (A) in the case of provider based

clinics. In either case, the A/B MAC (B) does not pay claims for services defined as

RHC/FQHC services. The A/B MAC (A) pays for such services through a prospectively

determined encounter rate.

Where an RHC or a FQHC is approved for billing other medical and health services to the A/B

MAC (B), the RHC or FQHC bills the A/B MAC (B) and is paid according to the method of

payment for the service provided.

Rural health clinic and Federally qualified health center services are described in the Medicare

Benefit Policy Manual, Chapter 13. That chapter provides that the following services usually

performed by physicians are included as services included in the encounter rate and therefore

are not separately billable for RHC/FQHC patients. They are:

• Professional services performed by a physician for a patient including diagnosis,

therapy, surgery, and consultation (See the Medicare Benefit Policy Manual, Chapter

15);

• Services and supplies incident to a physician’s services, as described in the Benefit

Policy Manual, Chapter 15;

• Nurse practitioner and physician assistant services (including the services of specialized

nurse practitioners and nurse midwives) that would be covered if furnished by a

physician, provided the nurse practitioner or physician assistant is legally permitted to

perform the services by the State in which they are performed;

• Services and supplies incident to the services of nurse practitioners and physician

assistants that would be covered if furnished incident to a physician’s services, and

• Visiting nurse services to the homebound.

However, the technical component of diagnostic services may be billed separately by the

physician to the A/B MAC (B), if provided. See Chapter 9, and the Medicare Benefit Policy

Manual, Chapter 13, for additional information on the definition of RHC/FQHC services.

Also, an RHC or FQHC may provide other items and services which are covered under Part B,

but which are not defined as RHC or FQHC services. They are listed in the Medicare Benefit

Policy Manual, Chapter 13. Independent RHCs/FQHCs bill the A/B MAC (B) for such

services. Provider-based RHC/FQHC services are billed to the A/B MAC (A) as services of

the parent provider.

Independent RHCs/FQHCs must enroll with the A/B MAC (B) in order to bill. (See the

Medicare Program Integrity Manual, Chapter 10, for enrollment instructions).