RHC General Information

10.1 - RHC General Information (Rev. 12832; Issued: 09-12-24; Effective:01-01-24; Implementation:10-14-24) Rural Health Clinics (RHCs) were established by the Rural Health Clinic Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas. RHCs have been eligible to participate in the Medicare program since March 1, 1978, and are paid an all-inclusive rate (AIR) for medically-necessary primary health services, and qualified preventive health services, furnished by an RHC practitioner. RHCs are defined in section 1861(aa)(2) of the Social Security Act (the Act) as facilities that are engaged primarily in providing services that are typically furnished in an outpatient clinic. RHC services are defined as: • Physician services; • Services and supplies furnished incident to a physician’s services; • NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), marriage and family therapist (MFT), and mental health counselor (MHC) services; and • Services and supplies furnished incident to an NP, PA, CNM, CP, MFT or MHC services. RHC services may also include nursing visits to patients confined to the home that are furnished by a registered professional nurse (RN) or a licensed professional nurse (LPN) when certain conditions are met. (See section 190 of this manual) To be eligible for certification as an RHC, a clinic must be located in a non-urbanized area, as determined by the U.S. Census Bureau, and in an area designated or certified within the previous 4 years by the Secretary, Health and Human Services (HHS), in any one of the four types of shortage area designations that are accepted for RHC certification. (See section 20 of this manual) In addition to the location requirements, an RHC must: • Employ an NP or PA; • Have an NP, PA, or CNM working at the clinic at least 50 percent of the time the clinic is operating as an RHC; • Directly furnish routine diagnostic and laboratory services; • Have arrangements with one or more hospitals to furnish medically necessary services that are not available at the RHC; • Have available drugs and biologicals necessary for the treatment of emergencies; • Meet all health and safety requirements; • Not be a rehabilitation agency or a facility that is primarily for mental health treatment; • Furnish onsite all of the following six laboratory tests: o Chemical examination of urine by stick or tablet method or both; o Hemoglobin or hematocrit; o Blood sugar; o Examination of stool specimens for occult blood; o Pregnancy tests; and o Primary culturing for transmittal to a certified laboratory. • Not be concurrently approved as an FQHC, and • Meet other applicable State and Federal requirements. RHCs can be either independent or provider-based. Independent RHCs are stand-alone or freestanding clinics and submit claims to a Medicare Administrative Contractor (A/B MAC). They are assigned a CMS Certification Number (CCN) in the range 3800-3974 or 8900-8999. Provider-based RHCs are an integral and subordinate part of a hospital (including a critical access hospital (CAH). They are assigned a CCN in the range 3400- 3499, 3975-3999, or 8500-8899. (NOTE: A provider-based CCN is not an indication that the RHC has met the qualifications for the special payment rules applicable to payment limits discussed in section 70.2 of this chapter.) The statutory requirements for RHCs are found in section 1861(aa) of the Act. The regulations pertaining to RHCs can be found at 42 CFR 405.2400 Subpart X and 42 CFR 491 Subpart A. For information on claims processing, see Pub. 100-04, Medicare Claims Processing Manual, chapter 9, http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/clm104c09.pdf For information on certification requirements, see Pub. 100-07, State Operations Manual, Chapter 2, and Appendix G, https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/som107c02.pdf