FQHC and RHC Global Encounters for MCO Enrollees – Examples

Revised: 09-12-2017

MHCP requires Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) to submit encounter claims to MHCP for members enrolled in a managed care organization (MCO) who are receiving services billed to the MCO as a global procedure or package. Use these examples as guidelines.

Example 1

Jane Doe is enrolled with an MCO. She receives her antepartum care through RHC1. RHC1 submits claims as follows:

· To the MCO: one claim with the last service date

· To MHCP: multiple claims, one for each service date on which a corresponding face-to-face encounter with an RHC professional took place.

Date of service	MCO claim: Bill one global procedure on last date of service	MHCP claims: Submit multiple encounters with revenue code 0519 and CPT code 59425
11/24/2007	No	Yes
12/15/2007	No	Yes
12/27/2007	No	Yes
1/08/2008	No	Yes
1/19/2008	Submit CPT 59425	Yes

Example 2

John Doe is enrolled with an MCO. He receives his dentures (impressions, dentures, adjustments) from FQHC2. FQHC2 submits claims as follows:

· To the MCO: one claim with the delivery date

· To MHCP: multiple claims, one for each service date that a corresponding face-to-face encounter with an FQHC professional took place.

Date of service	MCO claim: Bill one global procedure on delivery date	MHCP claims: Submit multiple encounters with revenue code 0519 and CDT code D5110
7/11/2008	No	Yes
7/22/2008	Submit CDT code D5110	Yes
8/01/2008	No	Yes
8/09/2008	No	Yes

Example 3

Joan Doe is enrolled in an MCO. She is seen by RHC1 for antepartum, delivery and postpartum care. RHC1 submits to MHCP one encounter claim for each of the first four visits using revenue code 0519 and procedure code 59400.

Date of service	MCO claim: Bill one global procedure	MHCP claims: Submit multiple encounters with revenue code 0519 and CPT code 59400
1/14/2008	No	Yes
2/07/2008	No	Yes
3/10/2008	No	Yes
4/19/2008	No	Yes

After several visits, the Joan Doe changes to another clinic. RHC1 submits a claim to the MCO with procedure code 59425, antepartum only, and the MCO pays the claim. RHC1 must submit new encounter reporting claims to MHCP with revenue code 0519 and procedure code 59425. MHCP will make settlement payment to RHC1 only for encounters based on 0519, 59425 claims because the MCO paid the 59425 claim.

Date of service	MCO claim: Bill one global procedure	MHCP claims: Submit multiple encounters with revenue code 0519 and CPT code 59425
1/14/2008	No	Yes
2/07/2008	No	Yes
3/10/2008	No	Yes
4/19/2008	Submit CPT 59425	Yes