Services non-Covered on RHC and FQHC Claims

90 - Services non-Covered on RHC and FQHC Claims (Rev. 13264, Issued:06-09-25; Effective: 06-02-25; Implementation: 06-02-25) Technical Services RHCs/FQHCs do not bill using TOBs 71X or 77X for technical components of services because they are not within the scope of Medicare-covered RHC/FQHC services. The associated technical components of services furnished by the RHC/FQHC are billed on other types of claims that are subject to applicable frequency limits edits. For services that can be split into professional and technical components, RHCs and FQHCs bill for the professional component as part of the AIR or the FQHC PPS payment and bill the MAC separately for the technical component. See Pub. 100-04, Medicare Claims Processing Manual Chapter 16, Section 30.1.1, for more information on how RHCs and FQHCs can bill the MAC for laboratory service: (http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf) and see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 60, for more information on how to bill the MAC for technical components of diagnostic services: (https://www.cms.gov/regulations-and- guidance/guidance/manuals/downloads/bp102c13.pdf.) Technical services/components associated with professional services/components performed by independent RHCs or FQHCs are submitted to the MAC in the designated claim format (837P or Form CMS-1500.) See Pub. 100-04, Medicare Claims Processing Manual, Chapter 12 (http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) and Chapter 26 (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf) of this manual for billing instructions. Technical services/components associated with professional services/components performed by provider-based RHCs or FQHCs are submitted by the base-provider on the appropriate TOB to the MAC in the designated claim format (837I or the UB-04 claim form); see the applicable chapters of this manual based on the base-provider type, such as for outpatient hospital services, see Pub. 100-04, Medicare Claims Processing Manual, Chapter 4 (http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf), for inpatient SNF services, chapter 6 (http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf), and for outpatient SNF services, Chapter 7 (http://www.cms.hhs.gov/manuals/downloads/clm104c07.pdf) Laboratory Services RHCs must furnish the following lab services to be approved as an RHC. However, these and other lab services that may be furnished are not included in the encounter rate and must be billed separately. • Chemical examinations of urine by stick or tablet method or both • Stick or tablet urine examine or both • Blood sugar. • Pregnancy tests; and • Collection of patient specimens to send to a certified lab for culturing. RHCs/FQHCs bill all laboratory services to their MAC under the host provider’s bill type and payment is made under the fee schedule. HCPCS codes are required for lab services. Venipuncture is included in the AIR and the PPS per diem payment and is not separately billable. Refer to Pub. 100-04, Medicare Claims Processing Manual, Chapter 16 for general billing instructions, (http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf.) Durable Medical Equipment (DME), ambulance services, hospital-based services, group services, and non-face-to-face services are also non-covered and are billed separately.