Special Instructions for Independent and Provider-Based Rural

10.2.2.2 - Special Instructions for Independent and Provider-Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs) Clinics/Federally Qualified Health Center (RHCs/FQHCs) (Rev. 13547; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26) Prior to July 1, 2025, pneumococcal, influenza and COVID-19 vaccines and their administration did not count as RHC/FQHC visits. The cost for these vaccines and their administration was included in the cost report and a visit was not billed for these services. RHCs did not report vaccines on the claim, TOB 71x. However, for FQHCs, if there was another reason for the visit, the vaccine and the administration code would be reported on the claim, TOB 77x, for informational and data collection purposes only. Coinsurance and deductible did not apply to these vaccines. Prior to January 1, 2025, payment for the hepatitis B vaccine was included in the RHC all- inclusive and FQHC PPS rate. RHCs/FQHCs did not bill for a visit when the only service involved was the administration of the hepatitis B vaccine. However, the charges of the vaccine and its administration could be included in the line item for the otherwise qualifying visit. A visit could not be billed if vaccine administration was the only service the RHC/FQHC provides. Effective January 1, 2025 through June 30, 2025, payment for the hepatitis B vaccine and its administration is through the cost report and no longer included in the RHC all- inclusive and FQHC PPS rate. The cost for these vaccines and their administration is included in the cost report and a visit is not billed for these services. RHCs do not report vaccines on the claim, TOB 71x. However, for FQHCs, if there was another reason for the visit, the vaccine and the administration code should be reported on the claim, TOB 77x, for informational and data collection purposes only. Coinsurance and deductible do not apply to these vaccines. Effective for dates of service on or after July 1, 2025, RHCs (bill type 71x) and FQHCs (bill type 77x), shall report all Part B preventive vaccines and their administration – pneumococcal, influenza, hepatitis B and COVID-19 -- on the claim. A visit/encounter is not required for these services; however, if reported on the same day, the vaccines and administrations shall receive a separate payment. Coinsurance and deductible do not apply to these vaccines. Although paid at the time of service, payments for these services must be annually reconciled with the RHC or FQHC’s actual vaccine and vaccine administration costs, to ensure these services are ultimately reimbursed at 100% of reasonable costs through the cost report. Note: An additional payment for influenza, pneumococcal, hepatitis B, COVID-19 vaccine administration in the home can be made, provided that a home visit meets all the requirements of both part 405, subpart X, for RHC services provided in the home, and § 410.152(h)(3)(iii) for the in-home additional payment for Part B preventive vaccine administration. See Pub. 100-02, Chapter 15, Section 50.4.4.2.E and Pub. 100-04 for more information.