PPS Rate

Where an FQHC provides an allowable healthcare service at the originating or distant site, the FQHC shall be reimbursed the applicable rate (PPS, APM or FFS).  If an FQHC is both the originating and distant site, and both sites render the same healthcare service, only the distant site will be reimbursed.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.24, 25, 26 & 27. (Accessed Mar. 2024).

In accordance with the District’s Prospective Payment System (PPS) or alternative payment methodology (APM) for FQHCs, the following reimbursement parameters apply:

• Originating Site: An FQHC provider must deliver an FQHC-eligible service in order to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site;
• Distant Site: An FQHC provider must deliver an FQHC-eligible service that is listed in Appendix A in order to be reimbursed the appropriate PPS, APM, or FFS rate; and
• Originating and Distant Site: If both the originating and the distant site are FQHCs, for both to receive reimbursement, each site must deliver a different PPS or APM service (e.g. medical or behavioral). If both sites submit a claim for the same PPS or APM service (e.g. medical), then only the distance site will be eligible to receive reimbursement.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4-5.,Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.5. P. 53, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.5, P. 51. FQHC Billing Manual, DC Medicaid 15.5, P. 53. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.5, p. 70. Inpatient Hospital Billing Guide, 11.5, p. 62 (Jan. 2024), Long-Term Care Billing Manual, 15.5, p. 53 (Sept. 2023) (Accessed Mar. 2024).

D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.8 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4. Physicians Billing Manual.  DC Medicaid.  (Jan. 2024) Sec. 15.4. P. 52, Clinic Billing Manual, DC Medicaid (Sept. 2023), Sec. 15.4, P. 50. FQHC Billing Manual, DC Medicaid 15.4, P. 52. (Oct. 2023), Behavioral Health Billing Manual (Feb. 2024) 14.4, p. 69, Outpatient Hospital Billing Guide, 15.8.4, p. 75 (Sept. 2023), Inpatient Hospital Billing Guide, 11.4, p. 61 (Jan. 2024), Long-Term Care Billing Manual, 15.4, p. 52 (Sept. 2023). (Accessed Mar. 2024).

If an FQHC does not elect the APM, it will be paid the PPS for every encounter, regardless of the type of encounter. New FQHC providers will be reimbursed at the PPS rate. The FQHC will receive a separate encounter rate for each type of FQHC service offered: primary care, behavioral health, preventive/diagnostic dental and comprehensive dental.

SOURCE: FQHC Billing Manual, DC Medicaid 17.1, P. 67-68. (Oct. 2023). (Accessed Mar. 2024).