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A recent policy decision dated 2/24/17 was made by AHCCCS regarding FQHC reimbursement for case management and behavioral health technicians. Mercy Care Plan and Mercy Maricopa Integrated Care (Mercy Maricopa) will be following this AHCCCS directive.
Key points from the policy decision are as follows:
FQHC Reimbursement for Case Management (T1016)
- FQHCs are entitled to reimbursement on a "per visit" basis at the PPS rate for "FQHC services" as defined in federal law
- FQHC services include the services of specific licensed professionals, services provided incident to those professional services, and "any other ambulatory services offered by the FQHC that are otherwise included in the (State Medicaid) plan"
- Under Medicaid regulations, "case management services means services furnished to assist individuals... in gaining access to needed medical, social, educational, and other services" and does not include "the direct delivery of underlying medical, educational, social, or other services"
- While FQHC services includes the services of a number of different types of health professionals, the definition of case management services effectively excludes case management from the definition of the services provided by those professionals
- Case management cannot be considered services provided incident to the services of the specified professionals because, to be considered "incident to," the services must be:
o Of a type commonly furnished in a physician's office;
o Furnished as an incidental, although integral, part of the professional's service;
and
o Furnished under the direct supervision of the professional. "Direct supervision"
means the professional "must be present in the office suite and immediately
available to furnish assistance and direction throughout the performance of the
procedure"
- Case Management cannot be considered an ambulatory service "otherwise included in the State Plan" because case management is not a covered service under the Arizona State Plan for Medicaid. While behavioral health case management is a service that is available under AHCCCS' Demonstration (the section 1115 waiver), case management is not a State Plan Service
- For these reasons, AHCCCS will not reimburse FQHCs for Case Management at the PPS visit rate
- AHCCCS will reimburse Case Management services (T1016) at the FFS rate schedule when provided by a provider within their scope of practice
- Policy effective with dates of service 10/1/2015 forward
- Will necessitate system changes by AHCCCS, Mercy Care Plan, and Mercy Maricopa to recognize and value/pay this service appropriately
FQHC Reimbursement for Behavioral Health Technician (BHT) provided services
- Allow FQHC reimbursement at the PPS visit rate for allowable services provided by a BHT only when those services qualify as services incident to the services of an FQHC practitioner consistent with federal requirements as stated above. This does not include Case Management
- Policy effective with dates of service 10/1/2015 forward
- Will necessitate a revision to Billing Instructions for FQHC reporting of BHT "participating provider" information as outlined below as well as system changes by AHCCCS, Mercy Care Plan, and Mercy Maricopa to capture and process this information appropriately (please see AHCCCS Policy Decision for further detail regarding billing instructions)
As always, don't hesitate to contact your Provider Relations Representative with any questions or comments at:
- Mercy Care Plan - 602-263-3000 or 800-624-3879, Express Service Code 631
- Mercy Maricopa Integrated Care - 800-564-5465
You can find this notice and all other provider notices posted on the Mercy Care Plan or Mercy Maricopa website.
Thanks for all you do!
QB 2463
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