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services that are payable under the FQHC benefit. An entity that qualifies as an FQHC isassigned a CCN in the range 1800-1989 and 1000-1199.FQHC services also include certain preventive primary health services. The law definesMedicare-covered preventive services provided by an FQHC as the preventive primaryhealth services that an FQHC is required to provide under section 330 of the PublicHealth Service (PHS) Act. Medicare may not cover some of the preventive services thatFQHCs provide, such as dental services, which are specifically excluded under Medicarelaw.There are 3 types of organizations that are eligible to enroll in Medicare as FQHCs: Health Center Program Grantees: Organizations receiving grants under section330 of the PHS Act, including Community Health Centers, Migrant HealthCenters, Health Care for the Homeless Health Centers, and Public HousingPrimary Care Centers; Health Center Program Look-Alikes: Organizations that have been identified byHRSA as meeting the definition of “Health Center” under section 330 of the PHSAct, but not receiving grant funding under section 330; and Outpatient health programs/facilities operated by a tribe or tribal organization(under the Indian Self-Determination Act) or by an urban Indian organization(under Title V of the Indian Health Care Improvement Act).NOTE: Information in this chapter applies to FQHCs that are Health Center ProgramGrantees and Health Center Program Look-Alikes. It does not necessarily apply to tribalor urban Indian FQHCs or grandfathered tribal FQHCs.An FQHC must: Provide comprehensive services and have an ongoing quality assurance program; Meet other health and safety requirements; Not be concurrently approved as an RHC; and

Meet all requirements contained in section 330 of the Public Health Service Act,including:o Serve a designated Medically-Underserved Area (MUA) or MedicallyUnderserved Population (MUP);o Offer a sliding fee scale to persons with incomes below 200 percent of thefederal poverty level; ando Be governed by a board of directors, of whom a majority of the membersreceive their care at the FQHC.Additional information on these and other section 330 requirements can be found athttp://bphc.hrsa.gov/.Per 42 CFR 413.65(n), only FQHCs that were operating as provider-based clinics prior to1995 and either a) received funds under section 330 of the PHS Act or b) weredetermined by CMS to meet the criteria to be a look-alike clinic, are eligible to becertified as provider-based FQHCs. Clinics that do not already have provider-basedstatus as an FQHC are no longer permitted to receive the designation.For information on claims processing, see to Pub. 100-04, Medicare Claims ProcessingManual, chapter 9, e/Manuals/downloads/clm104c09.pdf, and Pub. 100-07, StateOperations Manual chapter 2, sections 2825 and 2826, e/Manuals/downloads/som107c02.pdf.20 - RHC and FQHC Location Requirements(Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)To be eligible for certification as an RHC, a clinic must be located in 1) a non-urbanizedarea, as determined by the U.S. Census Bureau, and 2) an area designated or certifiedwithin the previous 4 years by the Secretary, HHS, in any one of the four types ofshortage area designations that are accepted for RHC certification as listed in section20.2.A clinic applying to become a Medicare-certified RHC must meet both the rural andunderserved location requirements. Mobile clinics must have a fixed schedule thatspecifies the date and location for services, and each location must meet the locationrequirements.Existing RHCs are not currently required to continue to meet the location requirements.RHCs that plan to relocate or expand should contact their Regional Office (RO) todetermine their location requirements.

FQHCs may be located in rural or urban areas. FQHCs that are Health Center ProgramGrantees or Look-Alikes must be located in or serve people from a HRSA-designatedMUA or MUP.20.1 - Non-Urbanized Area Requirement for RHCs(Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)The U.S. Census Bureau determines if an area is an urbanized area (UA). Any area thatis not in a UA is considered a non-urbanized area. A clinic located in an area that is not aUA would meet the RHC requirement for being in a non-urbanized area. Information onwhether an area is in an urbanized area can be found at http://factfinder.census.gov; orhttp://www.raconline.org; or by contacting the appropriate CMS RO athttp://www.cms.gov/RegionalOffices/.20.2 - Designated Shortage Area Requirement for RHCs(Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)The HRSA designates areas as MUAs/MUPs and/or Health Professional Shortage Areas(HPSAs). To be eligible for RHC certification, a clinic must be located in an area thathas one of the following types of shortage area designations: Geographic Primary Care HPSA; Population-group Primary Care HPSA; MUA (this does not include the population group MUP designation); or Governor-Designated and Secretary-Certified Shortage Area (this does notinclude a Governor’s Medically Underserved Population designation).No other type of shortage area designation is accepted for purposes of RHC certification.The designation cannot be more than 4 years old in order to meet the requirement ofbeing in a currently designated area. For RHC purposes, the age of the designation iscalculated as the last day of the year 4 years from the date of the original designation, orthe date the area was last designated. For example, a clinic that is located in an area thatwas most recently designated or updated on June 1, 2010, would be considered asmeeting this location requirement through December 31, 2014.Areas that are listed as “proposed for withdrawal” are considered designated. Thedesignation date is the date that the area was last updated, not when the area wasproposed for withdrawal. To determine the designation date of an area that is listed as“proposed for withdrawal”, contact HRSA’s Shortage Designation Branch [email protected] or call 1-888-275-4772.

30 - RHC and FQHC Staffing Requirements(Rev. 166, Issued: 01-31-13, Effective: 03-01-13, Implementation: 03-01-13)30.1 - RHC Staffing Requirements(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)In addition to the location requirements, an RHC must: Employ an NP or PA; and Have an NP, PA, or CNM working at the clinic at least 50 percent of the time theclinic is operating as an RHC.The employment may be full or part time, and is evidenced by a W-2 form from theRHC. If another entity such as a hospital has 100 percent ownership of the RHC, the W2 form can be from that entity as long as all the non-physician practitioners employed inthe RHC receive their W-2 from this owner.The following are examples of situations that would NOT satisfy the employmentrequirement: An NP or PA who is employed by a hospital that has an ownership interest in theRHC but is not physically present and working in the RHC; A CNM who is employed by the RHC; An Advanced Practice Registered Nurse who is not an NP or PA; or An NP or PA who is working as a substitute in an arrangement similar to a locumtenens physician.An RHC practitioner is a physician, NP, PA, CNM, CP, or CSW. At least one of thesepractitioners must be present in the RHC and available to furnish patient care at all timesthe RHC is in operation. A clinic that is open solely to address administrative matters orto provide shelter from inclement weather is not considered to be in operation during thisperiod and is not subject to the staffing requirements.An NP, PA, or CNM must be available to furnish patient care at least 50 percent of thetime that the RHC is open to provide patient care. This requirement can be fulfilledthrough any combination of NPs, PAs, or CNMs as long as the total is at least 50 percentof the time the RHC is open to provide patient care. Only the time that an NP, PA, orCNM spends in the RHC, or the time spent directly furnishing patient care in anotherlocation as an RHC practitioner, is counted towards the 50 percent time. It does notinclude travel time to another location, or time spent not furnishing patient care when inanother location outside the RHC (e.g. home, SNF, etc.).

A clinic located on an island that otherwise meets the requirements for RHC certificationis not required to employ an NP or PA, although it is still required to have an NP or PA atleast 50 percent of the time that the RHC is in operation (OBRA ’89, Sec 4024). Anisland is a body of land completely surrounded by water, regardless of size andaccessibility (e.g., bridges).As of July 1, 2014, RHCs may contract with non-physician practitioners (PAs, NPs,CNM, CPs or CSWs) if at least one NP or PA is employed by the RHC (subject to thewaiver provision for existing RHCs set forth at section 1861(aa)(7) of the Act).It is the responsibility of the RHC to assure that all staffing requirements are met and thatRHC practitioners provide services in accordance with state and federal laws andregulations.See section 80.4 of this chapter for information on productivity standards for RHCs.30.2 - RHC Temporary Staffing Waivers(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)An existing RHC may request a temporary staffing waiver if the RHC met the staffingrequirements before seeking the waiver, and either or both of the following occur: An NP or PA is not currently employed by the RHC. An NP, PA, or CNM is not furnishing patient care at least 50 percent of the timethe RHC operates.To receive a temporary staffing waiver, an RHC must demonstrate that it has made agood faith effort to recruit and retain the required practitioner(s) in the 90 day periodprior to the waiver request. Recruitment activities should begin as soon as the RHCbecomes aware that they will no longer be in compliance with this requirement. Goodfaith efforts can include activities such as advertising in an appropriate newspaper orprofessional journal, conducting outreach to an NP, PA, or CNM school, or otheractivities.Staffing waivers are for a period not to exceed 1 year. The waiver cannot be extendedbeyond 1 year, and another waiver cannot be granted until a minimum of 6 months haveelapsed since the prior waiver expired. RHCs should continue their recruitment activitiesduring the waiver period to avoid termination when the waiver period ends.An RHC will be terminated if any of the following occur:

The RHC does not meet the staffing requirements and does not request atemporary staffing waiver; The RHC requests a temporary staffing waiver and the request is denied due to alack of good faith effort to meet the requirements; The RHC does not meet the staffing requirements and is not eligible for atemporary staffing waiver because less than 6 months have passed since theexpiration of the previous waiver; The RHC reaches the expiration date of the temporary staffing waiver and has notcome into compliance; or Other non-compliance issue.30.3 - FQHC Staffing Requirements(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)FQHCs must have a core staff of appropriately trained primary care practitioners andmeet other clinical requirements. It is the responsibility of the FQHC to assure that allstaffing requirements are met and that FQHC practitioners provide services in accordancewith State and Federal laws and regulations. Additional information on FQHC staffingrequirements can be found at: .40 - RHC and FQHC Visits(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)An RHC or FQHC visit is a medically-necessary medical or mental health visit, or aqualified preventive health visit. The visit must be a face-to-face (one-on-one) encounterbetween the patient and a physician, NP, PA, CNM, CP, or a CSW during which timeone or more RHC or FQHC services are rendered. A Transitional Care Management(TCM) service can also be an RHC or FQHC visit. Services furnished must be within thepractitioner’s state scope of practice, and only services that require the skill level of theRHC or FQHC practitioner are considered RHC or FQHC visits.An RHC or FQHC visit can also be a visit between a home-bound patient and an RN orLPN under certain conditions. See section 190 of this chapter for information on visitingnursing services to home-bound patients.

Under certain conditions, an FQHC visit also may be provided by qualified practitionersof outpatient DSMT and MNT when the FQHC meets the relevant program requirementsfor provision of these services.RHC and FQHC visits are typically evaluation and management (E/M) type of servicesor screenings for certain preventive services. A list of qualifying visits for FQHCs islocated on the FQHC web page at Qualified-Health-Centers-FQHC-Center.html.40.1 – Location(Rev. 252, Issued: 12- 07-18, Effective: 01-01-19, Implementation: 01- 02-19)RHC or FQHC visits may take place in: the RHC or FQHC,the patient’s residence (including an assisted living facility),a Medicare-covered Part A SNF (see Pub. 100-04, Medicare Claims ProcessingManual, chapter 6, section 20.1.1), orthe scene of an accident.RHC and FQHC visits may not take place in: an inpatient or outpatient department of a hospital, including a CAH, ora facility which has specific requirements that preclude RHC or FQHC visits(e.g., a Medicare comprehensive outpatient rehabilitation facility, a hospicefacility, etc.).Qualified services provided to a RHC or FQHC patient are considered RHC or FQHCservices if: the practitioner is compensated by the RHC or FQHC for the services provided;the cost of the service is included in the RHC or FQHC cost report; and;other requirements for furnishing services are met.This applies to full and part time practitioners, and it applies regardless of whether thepractitioner is an employee of the RHC or FQHC, working under contract to the RHC orFQHC, or is compensated by the RHC or FQHC under another type of arrangement.RHCs and FQHCs should have clear policies regarding the provision of services in otherlocations and include this in a practitioner’s employment agreement or contract. RHCsand FQHCs providing RHC or FQHC services in locations other than the RHC or FQHCfacility must continue to meet all certification and cost reporting requirements. Servicesin other locations may be subject to review by the A/B MAC. RHC or FQHC servicesfurnished by an RHC or FQHC practitioner may not be billed separately by the RHC orFQHC practitioner, or by another practitioner or an entity other than the RHC or FQHC,even if the service is not a stand-alone billable visit. Services furnished to patients in any

type of hospital setting (inpatient, outpatient, or emergency department) are statutorilyexcluded from the RHC/FQHC benefit and may not be billed by the RHC or FQHC.40.2 - Hours of Operation(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)RHCs and FQHCs are required to post their hours of operations at or near the entrance ina manner that clearly states the days of the week and the hours that RHC or FQHCservices are furnished, and days of the week and the hours that the building is open solelyfor administrative or other purposes, if applicable. This information should be easilyreadable, including by people with vision problems and people who are in wheel chairs.Qualified services provided to an RHC or FQHC patient other than during the postedhours of operation are considered RHC or FQHC services when the practitioner iscompensated by the RHC or FQHC for the services provided, and when the cost of theservice is included in the RHC’s cost report.Services furnished at times other than the RHC or FQHC posted hours of operation toMedicare beneficiaries who are RHC or FQHC patients may not be billed to MedicarePart B if the practitioner’s compensation for these services is included in the RHC/FQHCcost report. (See Section 100 on Commingling).This applies to full and part time practitioners, practitioners who are employees,practitioners working under contract to the RHC or FQHC, and practitioners who arecompensated by the RHC or FQHC under another type of arrangement. RHCs andFQHCs should have clear policies regarding the provision of services at other times, andinclude this in a practitioner’s employment agreement or contract.40.3 - Multiple Visits on Same Day(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)Except as noted below, encounters with more than one RHC or FQHC practitioner on thesame day, or multiple encounters with the same RHC or FQHC practitioner on the sameday, constitute a single RHC or FQHC visit and is payable as one visit. This policyapplies regardless of the length or complexity of the visit, the number or type ofpractitioners seen, whether the second visit is a scheduled or unscheduled appointment, orwhether the first visit is related or unrelated to the subsequent visit. This would includesituations where an RHC or FQHC patient has a medically-necessary face-to-face visitwith an RHC or FQHC practitioner, and is then seen by another RHC or FQHCpractitioner, including a specialist, for further evaluation of the same condition on thesame day, or is then seen by another RHC or FQHC practitioner, including a specialist,for evaluation of a different condition on the same day.Exceptions are for the following circumstances only:

The patient, subsequent to the first visit, suffers an illness or injury that requiresadditional diagnosis or treatment on the same day (for example, a patient seestheir practitioner in the morning for a medical condition and later in the day has afall and returns to the RHC or FQHC). In this situation only, the FQHC woulduse modifier 59 on the claim and the RHC would use modifier 59 or 25 to attestthat the conditions being treated qualify as 2 billable visits; The patient has a qualified medical visit and a qualified mental health visit on thesame day (2 billable visits); or For RHCs only, the patient has an initial preventive physical exam (IPPE) and aseparate medical and/or mental health visit on the same day (2 or 3 billable visits).NOTE: These exceptions do not apply to grandfathered tribal FQHCs.40.4 - Global Billing(Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)Surgical procedures furnished in an RHC or FQHC by an RHC or FQHC practitioner areconsidered RHC or FQHC services. Procedures are included in the payment of anotherwise qualified visit and are not separately billable. If a procedure is associated witha qualified visit, the charges for the procedure go on the claim with the visit. Payment isincluded in the AIR when the procedure is furnished in an RHC, and payment is includedin the PPS methodology when furnished in an FQHC. The Medicare global billingrequirements do not apply to RHCs and FQHCs, and global billing codes are notaccepted for RHC or FQHC billing or payment.Surgical procedures furnished at locations other than RHCs or FQHCs may be subject toMedicare global billing requirements. If an RHC or FQHC furnishes services to a patientwho has had surgery elsewhere and is still in the global billing period, the RHC or FQHCmust determine if these services have been included in the surgical global billing. RHCsand FQHCs may bill for a visit during the global surgical period if the visit is for aservice

Medicare program since March 1, 1978, and are paid an all-inclusive rate (AIR) for . NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services; and . PA, CNM, or CP services. RHC services may also include nursing visits to patients co