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Meridian Medicare-Medicaid Plan Billing Reminders for Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) Claims

Date: 05/18/23

Meridian Medicare-Medicaid Plan (MMP) has recently reviewed MMP FQHC claims. Opportunities were identified to apply appropriate reimbursement levels, and adjustments were made to Meridian’s claims processing system to ensure proper billing methods and reimbursement methodologies were followed.

Please remember the following:

  • FQHC and RHC claims should be billed on a UB04 following Medicare Guidelines.
  • For FQHC, one of the following “G codes” should be billed in addition to the applicable procedure code describing the services rendered: G0466, G0467, G0468, G0469, G0470, or G2025.
  • For RHC, revenue code 052X should be billed with the appropriate CPT or HCPCS code. T1015 may be billed on Medicare claims; however, this CPT code is non-covered by Medicare and will deny as EX 82 DENY- NON-covered Services on the Medicare claim. Once a claim crosses over to Medicaid, T1015 will pay $0 with the following adjudication code: EXFQ- REIMBURSEMENT FOR PROCEDURE INCLUDED IN ENCOUNTER RATE.
  • For FQHC claims, any payment on the Medicaid side will be applied to the appropriate G code.
  • Claims billed on a CMS 1500 with T1015 will deny as EXF2-DENY: FQHC, ERC, RHC MMAI MUST BE BILLED UNDER MCARE RULES.

FQHC and RHC claims for MMP members are processed to pay as two claims. If applicable, the Medicare claim will pay at the Medicare Clinic rate less the 20% co-insurance. The Medicaid claim will only pay the 20% co-insurance up to the Medicaid PPS rate.

 

EXAMPLE

Medicare PPS Rate

$176.92

Less 20% co-insurance ($35.38)

$141.54

Less 2% sequestration ($2.83)

$138.71

Medicare payment

138.71

Medicaid PPS rate

$163.49

Medicare Co-insurance amount

$35.38

Medicaid payment

$35.38

For FQHC, it is essential to note that even if the claim is billed with the appropriate G code and T1015, the Medicaid cross-over claim will pay on the G code, not the T1015.

Meridian recognizes that previous Medicare-Medicaid Plan (MMP) claims may have been reimbursed incorrectly. Claims are being reviewed for over and underpayments. Any underpayments identified will be reprocessed if the claim was appropriately billed.

If the claim was erroneously billed on a CMS1500 with a T1015 or aUB04 without the appropriate G code, we request that providers submit a corrected claim and void the original claim to adjust reimbursements. Claims that have been overpaid will be identified, and a separate overpayment notification will be sent. Meridian will override the timely filing requirement for any adjustments or resubmitted claims.