Ala. Admin. Code r. 560-X-48-.01

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-48-.01 - General

(1) Federally Qualified Health Centers (FQHCS) are defined as health care centers which meet one of the following requirements:

(a) receives a grant under Section 329, 330, 340, or 340A of the Public Health Services Act;

(b) meets the requirements for receiving such a grant as determined by the Secretary based on the recommendations of the Health Resources and Services Administration within the Public Health Service;

(c) qualifies through waivers of the requirements described above as determined by the secretary for good cause; or

(d) functions as outpatient health programs or facilities operated by a tribe or tribal organization under the Indian Self-Determination Act ( Public Law 93-638).

(2) Services provided by an FQHC include, but are not limited to medically necessary diagnostic and therapeutic services and supplies, provided by a physician, physician assistant, nurse midwife, nurse practitioner, clinical psychologist, clinical social worker, and services and supplies incidental to such services as would otherwise be covered if furnished by a physician as an incident to a physician service. Any other ambulatory service offered by the center which is included in the State Plan is covered except for home health. Home health services are excluded as an FQHC service because home health services are available on a statewide basis.

(a) Billable services must be designated by procedure codes from the Physicians Current Procedure Terminology (CPT) or by special procedure codes designate by Medicaid for its own use.

(3) Reimbursement for other ambulatory services covered by the State Plan includes but is not limited to Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for individuals under age 21 family planning, prenatal, and dental for individuals under age 21. These services are subject to policies and routine benefit limitations for the respective program areas. Refer to Chapters 11, 14, 43, and 15 of the Administrative Code for details. These services are not counted in the routine benefit limits for medical encounters.

(4) FQHC clinic visits and inpatient services are subject to the same routine benefit limitations as physician visits. Refer to Chapter 6 of the Administrative Code for details.

(5) The time filing limit for FQHC Providers shall be 365 days after the date of service. Claims received after this time limit will be treated as outdated in accordance with Rule 560-X-1-.17.

Author: Carol Akin, Associate Director, Clinic/Ancillary Services

Ala. Admin. Code r. 560-X-48-.01

Emergency rule effective October 1, 1990. Permanent rule effective January 15, 1991. Amended: April 15, 1993. Amended: Filed August 6, 1993; effective September 11, 1993. Amended: Filed December 7, 1993. Amended: January 12, 1994. Amended: Filed April 6, 1994; effective May 13, 1994. Amended: Filed April 5, 1995; effective May 10, 1995. Amended: Filed December 9, 1996; effective January 13, 1997. Amended: Filed November 5, 1997; effective December 10, 1997. Amended: Filed May 11, 2001; effective June 15, 2001.

Statutory Authority: State Plan; Attachment 3.1-A, §6404 Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239); Title XIX, Social Security Act.