Federally Qualified Health Care & Rural Health Care Billing Manuals

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Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Providers must be enrolled as a Health First Colorado (Colorado’s Medicaid Program) provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to the Health First Colorado

 

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing FQHC and RHC services.

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Federally Qualified Health Centers (FQHCs)

The U.S. Department of Health and Human Services certifies Federally Qualified Health Centers (FQHCs) that qualify as FQHCs. FQHCs may be either freestanding or federally defined as "provider based". Federally Qualified Health Center services must be medically necessary and provided in outpatient settings only. Inpatient hospital stays are not included.

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Rural Health Clinics (RHCs)

Rural Health Clinics are clinics that are located in rural areas and that have been certified under Medicare. These clinics are either freestanding or hospital affiliated. Rural Health Clinics cannot be rehabilitation facilities or facilities primarily for the care and treatment of mental illness.

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Billing Information

Refer to the General Provider Information manual for general billing information.

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Federally Qualified Health Center (FQHC) Benefits

Core services that are medically necessary are FQHC benefits. Core benefits include the following outpatient services:

  • Physician services
  • Physician assistant services
  • Nurse practitioner services
  • Nurse midwife services
  • Clinical psychologist services
  • Clinical social worker services
  • Pneumococcal & influenza vaccines and administration
  • Services and supplies incidental to professional services
  • Part-time or intermittent nursing care and related medical supplies for homebound individuals
  • Other reimbursable ambulatory services
  • Dental

 

Federally Qualified Health Centers that offer the Nurse Home Visitor Program (NHVP) and/or the Prenatal Plus Program are instructed to submit fee-for-service claims for services rendered under these programs. Claims for services should be submitted using the CMS 1500 and will be reimbursed based upon the supplemental fee schedule. All services provided under these two programs must be excluded from the cost report as they are not considered when determining the encounter rates paid to FQHCs.

The NHVP is a home visitation program available to first-time moms in Colorado. Health First Colorado reimburses NHVP for targeted case management services provided to Health First Colorado members. The Prenatal Plus Program provides women access to a multidisciplinary care team throughout their pregnancy. Both programs have unique payment models and reporting mechanisms that necessitate Health First Colorado reimbursement remain separate from the encounter rate.

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Rural Health Clinic (RHC) Services

Rural Health Clinic services include:

  • Services provided by a physician
  • Services provided by physician assistants, nurse practitioners, and nurse midwives under the supervision of a physician
  • Incidental related services and supplies, including visiting nurse care, and related medical supplies
  • Other ambulatory services which meet specific programmatical requirements
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services which are not part of RHC services and meet EPSDT requirements
  • Clinical psychologist services
  • Clinical social worker services

 

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FQHC and RHC Coding

Both FQHCs and RHCs use revenue codes to bill Health First Colorado.

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FQHCs and RHCs

The valid revenue codes for reimbursement for services to the Health First Colorado are:

Facility Revenue code Service
FQHC 529 Physical Health
RHC 521 Physical Health
FQHC/RHC 900 Behavioral Health

Freestanding FQHC and RHC services are priced at an encounter rate. All routine services are included in the encounter rate.

In order to provide the Health First Colorado program with basic clinical information for use in evaluating services requested and received by Health First Colorado members, FQHCs are required to include all CPT codes and HCPCS codes for services provided during a visit on claims. In order to be reimbursed, an FQHC or RHC that submits a UB-04 or 837 Institutional (837I) electronic transaction must have at least one (1) claim line that identifies revenue code 0529 for FQHCs or revenue code 0521 for RHCs. All other lines on the claim should have the revenue code most appropriate for the service. The line item with revenue code 0529 or 0521 can appear at any line on the claim and with any procedure code.

CDT dental codes must be included on dental claims.

Beginning July 1, 2014, all FQHC claims for dental services and dentures must be submitted to DentaQuest, the Dental Administrative Service Organization (ASO), on the 2006 ADA Dental Claim form or by submitting the 837D electronic transaction via the DentaQuest Provider Web Portal. Information about claims submission for dental services can be found in the Office Reference Manual (ORM) under ‘DentaQuest Resources’ located on the Dentist page of DentaQuest’s website.

Rates for FQHCs are determined using an alternative payment methodology.

Beginning on October 31, 2016, claims for encounters that have any Evaluation & Management (E&M) procedure on the claim must be billed to MMIS. The Regional Accountable Entities (RAEs) will not reimburse claims which include an E&M procedure even when the diagnosis code identifies the service as behavioral health.

For Colorado Medicaid a billable encounter at an FQHC is an in person face to face visit with a Health First Colorado member. There is no carve out paying fee schedule for telemedicine services. The costs and salaries associated with a telemedicine visit are appropriately included in the cost report, but the service is not a billable encounter. The services are appropriately reimbursed through the prospective payment system by including the costs in the reimbursement calculation.

For FQHCs, Colorado Medicaid does not cover the professional component of an imaging service as a billable encounter. Colorado Medicaid only allows reimbursement for a visit, which is a face-to-face encounter between a Medicaid member and a provider listed at 10 CCR 2505-10 sections 8.700.6 and 8.700.1. A direct visualization by a physician without the member present is not billable as an encounter. For the technical component of an imaging service, when free standing FQHCs own the equipment, the costs are accounted for in the Prospective Payment System (PPS) rate and the technical component is not billable. When free standing FQHCs order imaging from another provider, the technical component services are billed by the rendering provider. For hospital based FQHCs, the costs of imaging and labs are removed from the cost report when determining the encounter rate. Since the costs are removed from the cost report, the technical component of imaging may be billed separately to Colorado Medicaid by the hospital.

Effective March 1, 2016, RHCs and their providers are able to bill for Long-Acting Reversible Contraceptive (LARC) devices on a fee-for-service (FFS) basis, outside of the normal RHC billable encounter rate. Long-acting reversible contraceptive devices can be billed on the CMS 1500 claim form using the appropriate Healthcare Common Procedure Coding System (HCPCS) codes for the devices.

Effective July 1, 2018, FQHCs and RHCs may be reimbursed by Health First Colorado for short term behavioral health services Fee-for-Service (FFS) for up to six (6) sessions per episode of care. An episode of care is currently defined as a 12-month period. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the Regional Accountable Entity (RAE) and will be reimbursed by the RAE under the capitated behavioral health benefit. These claims should be billed using the 900 revenue code. The following procedure codes may be billed under the short term behavioral health services in the primary care setting policy:

90791 Diagnostic Evaluation without Medical Services
90832 Psychotherapy – 30 minutes
90834 Psychotherapy – 45 minutes
90837 Psychotherapy – 60 minutes
90846 Family Psychotherapy (w/o patient)
90847 Family Psychotherapy (with/patient)

If a member receives both an FFS short term behavioral health service and a medical service on the same day, a FQHC must submit two claims, one with the short term behavioral service using revenue code 900 and one with the medical service using revenue code 529 for two encounter rate payments from Health First Colorado.

A visit that includes an FFS short term behavioral health service and other behavioral health services should include all behavioral health services in the visit on the claim billed to Health First Colorado.

 

Zero Pay Claims
If an FQHC submits claims that include two codes that are included in the National Correct Coding Initiative (NCCI) Procedure to Procedure edits, the claim may result in $0 pay. FQHCs are required to comply with NCCI coding. Complying with NCCI coding will prevent $0 pay claims. Failure to include the National Drug Code (NDC) on claims that include a procedure for a physician-administered drug may result in $0 pay.

National Drug Code (NDC)
FQHCs and RHCs must include all non-carved out physician-administered drugs on claims when they are part of the treatment. Claims and encounters for physician-administered drugs purchased through the 340B program should include the "UD" code modifier on the 837P, 837I and CMS 1500 claim formats. For any physician-administered drugs not purchased through the 340B program, no code modifier is required. A valid national drug code (NDC) number must be included on all claims and encounters for physician-administered drugs. To assist providers with billing, an HCPCS/NDC crosswalk can be found under Appendices at https://www.colorado.gov/HCPF/billing-manuals.

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UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for the Health First Colorado as those indicated in the NUBCUB-04 Reference Manual.

All code values listed in the NUBCUB-04 Reference Manual for each form locator may not be used for submitting paper claims to the Health First Colorado. The appropriate code values listed in this manual must be used when billing the Health First Colorado.

The UB-04 Certification document (located after the Sterilizations, Hysterectomies, and Abortions instructions and in the Provider Services Forms section) must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form. Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to the Health First Colorado for FQHC and RHC services.

Form Locator and Labels Completion Format Instructions
1. Billing Provider Name, Address, Telephone Number Text Abbreviate the state using standard post office abbreviations. Enter the telephone number.
  • Street
  • City
  • State
  • Zip Code
Abbreviate the state using standard post office abbreviations. Enter the telephone number.
2. Pay-to Name, Address, City, State Text Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
  • Street/Post Office box City
  • State Zip Code
  • Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control Number Up to 20 characters: Letters, numbers or hyphens Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number 17 digits Optional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill 3 digits Required
RHC: Use type of Bill 71X
FQHC: Use type of Bill 77X for outpatient
Digit 1 Frequency
0 Non-Payment/Zero Claim
1 Admit through discharge claim
2 Interim - First claim
3 Interim - Continuous claim
4 Interim - Last claim
7 Replacement of prior claim
8 Void of prior claim
5. Federal Tax Number None Submitted information is not entered into the claim processing system.
6. Statement covers period From/Through From:6 digits MMDDYY
Through: 6 digits MMDDYY
Required
Each date of service must be billed on a separate line. Split an entire month into two claims. This FL must reflect the beginning and ending dates of service listed on the detail dates of service lines.
8a. Patient Identifier   Submitted information is not entered into the claim processing system.
8b. Patient Name Up to 25 characters; letters & spaces Required
Enter the member's last name, first name and middle initial.
9a. Patient Address – Street Characters Letters & numbers Required
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address – City Text Required
Enter the member's city as determined at the time of admission
9c. Patient Address – State Text Required
Enter the member's state as determined at the time of admission.
9d. Patient Address – ZIP Digits Required
Enter the member's zip code as determined at the time of admission.
9e. Patient Address – Country Code Digits Optional
10. Birthdate 8 digits (MMDDYYYY) Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDYYYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex 1 letter Required
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date 6 digits Not Required
13. Admission Hour 6 digits Not Required
14. Admission Type 1 digit Conditional
Complete for emergency visits.
1 – Emergency
Member requires immediate intervention as a result of severe, life threatening or potentially disabling conditions.
Exempts outpatient hospital claims from co-payment and PCP referral only if Revenue Code 0450 or 0459 is present. This is the only benefit service for an undocumented alien.
If span billing, emergency services cannot be included in the span bill and must be billed separately from other outpatient services.
15. Source of Admission 1 digit Not Required
16. Discharge Hour 2 digits Not Required
17. Patient Discharge Status 2 digits Not Required
18-28. Conditions Codes 2 digits Conditional Complete with as many codes necessary to identify conditions related to this bill that may affect payer processing.
Condition Codes
01 Military service related
02 Employment related
04 Information only bill
05 Lien has been filed
06 ESRD member - First 30 months entitlement
07 Treatment of non-terminal condition/hospice member
17 Member is homeless
25 Member is a non-US resident
39 Private room medically necessary
60 -DRG (Day outlier)
Renal dialysis settings
71 Full care unit
72 Self care unit
73 Self-care training
74 Home care
75 Home care - 100 percent reimbursement
76 Back-up facility
Special Program Indicator Codes
A1 EPSDT/CHAP
A2 Physically Handicapped Children's Program
A4 Family Planning
A6 PPV/Medicare
A9 Second Opinion Surgery
B3 Pregnancy Indicator
PRO Approval Codes
C1 Approved as billed
C2 Automatic approval as billed - Based on focused review
C3 Partial approval
C4 Admission/Services denied
C5 Post payment review applicable
C6 Admission preauthorization
C7 Extended authorization
29. Accident State 2 digits Not required
31 – 34. Occurrence Code/Date 2 digits & 6 digits Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
Occurrence Codes:
1 Accident/Medical Coverage
2 Auto Accident - No Fault Insurance Involved
3 Accident/Tort Liability
4 Accident/Employment Related
5 Other Accident/No Medical Coverage or Liability Coverage
6 Crime Victim
20 Date Guarantee of Payment Began
24* Date Insurance Denied
25* Date Benefits Terminated by Primary Payer
26 Date Skilled Nursing Facility Bed Available
27 Date of Hospice Certification or Re- certification
40 Scheduled Date of Admission (RTD)
50 Medicare Pay Date
51 Medicare Denial Date
55 Date of Death
A3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line A
B3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line B
C3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line C
*Other Payer occurrence codes 24 and 25 must be used when applicable. The claim must be submitted with the third-party information
35-36. Occurrence Span Code From/ Through 2 & 6 digits Not required
38. Responsible Party Name/Address None Leave blank
39 – 41. Value Codes and Amounts 2 characters and up to 9 digits Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
01 Most common semiprivate rate (Accommodation Rate)
06 Medicare blood deductible
14 No fault including auto/other
15 Worker's Compensation
31 Member Liability Amount
32 Multiple Member Ambulance Transport
37 Pints of Blood Furnished
38 Blood Deductible Pints
40 New Coverage Not Implemented by HMO
45 Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49 Hematocrit Reading - EPO Related
58 Arterial Blood Gas (PO2/PA2)
68 EPO-Drug
80 Covered Days
81 Non-Covered Days
Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C
42. Revenue Code 3 digits Required
FQHCs
  • FQHC Medical Claims
    Use revenue code 0529 on at least one line of the claim regardless of the type of service identified in locator 44. All other lines should use the revenue code appropriate for the service.
  • FQHC Dental Claims
    For claims with dates of service prior to July 1, 2014, use revenue code 529 on each line of the claim regardless of the type of services identified in locator 44. For claims with dates of service after July 1, 2014, refer to the Office Reference Manual (ORM) under ‘DentaQuest Resources’ located on the Dentist page of DentaQuest’s website.
RHCs
Use revenue code 0521 on one line of the claim regardless of the type of service identified in locator 44. All other lines should use the revenue code appropriate for the service and list other revenue codes as informational.
43. Revenue code Description Text Required
Enter the revenue code description or abbreviated description.
When reporting an NDC:
  • Enter the NDC qualifier of "N4" in the first two positions on the left side of the field, immediatelyu followed by the 11-digit NDC numeric code
  • Enter one space for separation.
  • Enter the NDC unit of measure qualifier (examples include):
    • F2 – International Unit
    • GR – Gram
    • ML – Milliliter
    • UN – Units
  • Enter the NDC unit of measure quantity
Example:
42 REV.CD. 43 DESCRIPTION
0636 N467066000501 ME.016
44. HCPCS/Rates/ HIPPS Rate Codes 5 digits FQHC
Required
There may be multiple lines, each identified by revenue code 529 in locator 42. For each line enter a valid CPT code or HCPCS code that reflects the services rendered during the encounter. This includes any medical, laboratory, radiology, physical therapy, occupational therapy, pharmacy, supply or other service rendered during the encounter.

CPT and HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.

On dental claims the D-code must be put in locator 44 on each line for dates of services prior to July 1, 2014. For dates of services after July 1, 2014, refer to the Office Reference Manual (ORM) under ‘DentaQuest Resources’ located on the Dentist page of DentaQuest’s website.

RHC
Conditional
Enter only the HCPCS code for each detail line.

Complete for laboratory, radiology, physical therapy, occupational therapy, and hospital based transportation. When billing HCPCS codes, the appropriate revenue code must also be billed.

Services Requiring HCPCS
With the exception of outpatient lab and hospital-based transportation, outpatient radiology services can be billed with other outpatient services.

HCPCS codes must be identified for the following revenue codes:
  • 32X Radiology – Diagnostic
  • 33X Radiology – Therapeutic
  • 34X Nuclear Medicine
  • 35X CT Scan
  • 40X Other Imaging Services
  • 61X MRI


HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.
45. Service Date 6 digits Required
FQHC
Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span

RHC

For span bills only

Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span
46. Service Units Up to 3 digits Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit)
47. Total Charges Up to 9 digits Required
Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total in line 23 is required for all charges.
48. Non-covered Charges Up to 9 digits Required
Enter incurred charges that are not payable by the Health First Colorado.
Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges). Each column requires a grand total.
Non-covered charges cannot be billed for outpatient hospital laboratory or hospital-based transportation services.
50. Payer Name 1 letter and text Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
Source Payment Codes
B Workmen's Compensation
C Medicare
D Health First Colorado
E Other Federal Program
F Insurance Company
G Blue Cross, including Federal Employee Program
H Other - Inpatient (Part B Only)
I Other
Line A Primary Payer
Line B Secondary Payer
Line C Tertiary Payer
51. Health Plan ID 8 digits Required
Enter the provider's Health Plan ID for each payer name. Enter the eight-digit Health First Colorado
Program provider number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of Information None  
53. Assignment of Benefits None  
54. Prior Payments Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount Due Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI) 10 digits Required
Enter the billing provider's 10-digit National Provider Identifier(NPI).
57. Other Provider ID   Submitted information is not entered into the claim processing system.
58. Insured's Name Up to 30 characters Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique ID Up to 20 characters Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name 14 letters Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number 17 digits Conditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization Code Up to 18 characters Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control Number   Conditional
65. Employer Name Text Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier   Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0   ICD-10-CM (DOS 10/1/15 and after)
9   ICD-10-CM (DOS 9/30/15 and before)
67. Principal Diagnosis Code Up to 6 digits Required
Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
Use diagnosis code
Z00.00-10
Z00.110-Z00.111
Z00.121-Z00.129
Z00.6-Z00.8
Z02.0-Z02.6
Z02.81-Z02.89
Z76.2 for EPSDT screenings.
67A. – 67Q. – Other Diagnosis 6 digits Optional
Enter the exact diagnosis code corresponding to additional conditions that co exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
69. Admitting Diagnosis Code 6 digits Not required
70. Patient Reason Diagnosis   Submitted information is not entered into the claim processing system.
71. PPS Code   Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code) 6 digits FQHC
Required if known

Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".

RHC
Optional

Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date 7 characters and 6 digits Required
Enter the procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format.
Apply the following criteria to determine the principle procedure:
  • The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment.
  • The principal procedure is most related to the primary diagnosis.
74A. Other Procedure Code/Date 7 characters and 6 digits Conditional

Complete when there are additional significant procedure codes.

Enter the procedure codes identifying all significant procedures other than the principle procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principle diagnosis. Enter the date using MMDDYY format.
76. Attending NPI – Required





Attending Last/First Name
NPI – 10 digits






Text
Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL – Enter "1D" for Medicaid
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI   Submitted information is not entered into the claim processing system.
78 – 79. Other ID





NPI – Conditional
NPI – 10 digits Conditional
Complete when attending physician is not the PCP or to identify additional physicians.
NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. The Health First Colorado does not require that the PCP number appear more than once on each claim submitted.
The attending physician's last and first name are optional.
80. Remarks Text Enter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code – QUAL/CODE/VALUE (a-d)   Submitted information is not entered into the claim processing system.

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FQHC Claim Example

FQHC Claim Example

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FQHC Crossover Claim Example

FQHC Crossover Claim Example

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FQHC with RAE Diagnosis Code Claim Example

FQHC RAE Claim Example

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RHC Claim Example

RHC Claim Example

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RHC Crossover Claim Example

RHC Crossover Claim Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

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Sterilization, Hysterectomies, and Abortions

For more information on Sterilization, Hysterectomies, and Abortions, please see the Obstetrical Care Billing Manual on the Billing Manuals web page under CMS 1500 drop-down menu.

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Institutional Provider Certification

The Institutional Provider Certification form is available on the Provider Forms web page under the Claim Forms and Attachments drop-down menu.

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FQHC/RHC Revisions Log

Revision Date Addition/Changes Made by
12/01/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive. HPE (now DXC)
1/19/2017 Updates based on the Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
2/9/2017 Added RAE E&M policy and Type of Bill 77x HCPF
2/9/2017 Made formatting changes to references of FQHCs and RHCs HCPF
5/17/2017 Updated the Freestanding FQHCs and RHCs section HCPF
5/17/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
1/2/2018 Revenue Code Description – instructions for reporting an NDC DXC
6/22/2018 Updated general billing & timely filing, changed BHO to RAE HCPF
7/11/2019 Updated Appendices’ links and verbiage DXC
8/21/2019 Added language for valid revenue codes HCPF
8/22/2019 Updated links, removed duplicated information HCPF
11/20/2019 Added clarification to 0529 HCPF

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