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FQHC and RHC Providers Claims For PCCM Clients Require Referring Provider Effective April 1, 2010

Information posted February 4, 2010

Effective April 1, 2010, Federally Qualified Health Center (FQHC) and rural health clinic (RHC) providers must submit the referring provider's National Provider Identifier (NPI) on claims for outpatient hospital or professional services that are provided to a PCCM client for whom they are not the primary care provider. If the referring provider's NPI is not submitted on a claim for outpatient hospital or professional services that were provided to a PCCM client for whom they were not the primary care provider, the claim will be denied. UB-04 CMS-1450 Instructions The referring provider's NPI must be included in block 78 or 79 of the UB-04 CMS-1450 paper claim form. The block should include the referring provider's complete name and NPI. The rest of the claim form should be completed normally. The full instructions for completing the UB-04 CMS-1450 paper claim form can be found in the 2009 Texas Medicaid Provider Procedures Manual, Section 5.6, "UB-04 CMS1450 Claim Filing Instructions," on page 5-33. CMS-1500 Instructions The referring provider's NPI must be included in block 17b of the CMS-1500 paper claim form. The referring provider's complete name should be included in block 17. The rest of the claim form should be completed normally. The full instructions for completing the CMS-1500 paper claim form can be found in the 2009 Texas Medicaid Provider Procedures Manual, Section 5.5, "CMS-1500 Claim Filing Instructions," on page 5-26. Self-Referred Client Services PCCM clients can refer themselves for some services and, therefore, do not require a referral from a primary care provider. The following are self-referred services for PCCM clients and the claim requirements that FQHC providers must use when submitting claims for these services. FQHC providers may use their facility provider ID when submitting:

FQHC Self-Referred Service Claim Requirement

Emergency services Family planning (FP) Texas Health Steps (THSteps) services and immunizations Case management for Early Childhood Intervention (ECI) Case management for Children and

Emergency diagnosis FP diagnosis and procedure codes THSteps procedure codes Case management codes Case management codes

Pregnant Women (CPW) Obstetric services Gynecological services TH modifier GY modifier

Behavioral health services Psychological procedure code RHC providers may submit claims for the following self-referred services using their facility provider ID:

RHC Self-Referred Service Claim Requirement

Obstetric services Gynecological services Behavioral health services

TH modifier GY modifier Psychological diagnosis code

Providers performing services at an RHC location may submit claims for the following self-referred services using their individual provider ID:

RHC Self-Referred Service Claim Requirement

Emergency services Family planning THSteps services

Emergency diagnosis FP diagnosis and procedure codes THSteps procedure codes

Reminder: Unless providing after-hours care, claims submitted for services other than those listed above that are provided to PCCM clients who are not assigned on a panel report for an FQHC or RHC must include the client's required primary care provider information in the Referring Provider field on the appropriate claim form. Claims that are not submitted accordingly are subject to claims denial. Providers can find complete information about self-referred client services in the 2009 Texas Medicaid Provider Procedures Manual, section 7.1.18, "Primary Care Provider Requirements and Information," on page 7-10. Providers can find complete information about out-of-state and border providers who perform services to migrant farm workers in the March/April 2010 Texas Medicaid Bulletin No. 228 on page 29. For more information, call the PCCM Provider Helpline at 1-888-834-7226.

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