Definition of a Visit

FQHC encounters are face-to-face contacts between a patient and an FQHC covered professional for preventive and/or medically necessary services and include the FQHC facility costs, and all services, and supplies associated with the FQHC covered professional’s services. FQHC encounters also include services and/or supplies that are commonly furnished in a practitioner’s office, without charge, included in the FQHC’s facility costs, and/or furnished as incidental although an integral part of professional services.

Contacts with one or more health care professionals whether more than one is/are qualified (PPS reimbursable) or a combination of qualified and unqualified (not PPS reimbursable) and multiple contacts with the same qualified health care professional that take place on the same day and at a single location constitute a single encounter. Medicaid will only pay for one encounter per day, except as described in 21.4.1.1.

Billable FQHC encounters are face-to-face contacts between a patient and a FQHC covered professional. They include preventive services and medically necessary services such as lab services, diagnostic services such as EKGs, x-ray services (including ultrasounds), dental services, medical services, EPSDT services, family planning services, and prenatal services. Billable FQHC encounters for recipients in the fee-for-service Medicaid program are submitted to MQD for payment through its Fiscal Agent. Billable encounters for recipients in a QI plan are submitted to the plan in which the patient is enrolled.

Non-billable FQHC encounters are: (1) non-face-to-face contacts between a patient and FQHC covered health care professional; (2) face-to-face contacts between a patient and FQHC covered health care professional for non-FQHC covered services; and (3) face-to-face contacts between a patient and a FQHC non-covered professional such as a physical therapist, dental hygienist, and/or audiologist Health screening services in a clinic or community health fair setting such as weight check only or blood pressure check only are not eligible for FQHC PPS reimbursement.

SOURCE: HI Medicaid Provider Manual (FQHC) (March 2016), p. 9-10. (Accessed Feb. 2024).