Federally Qualified Health Center (FQHC)/Non-FQHC - PT (31)

Federally Qualified Health Center (FQHC)/Non-FQHC - PT (31)

The Federally Qualified Health Center (FQHC)/Non-FQHC program is identified by Kentucky Medicaid as Provider Type (31) and may bill Kentucky Medicaid using this provider type number. To provide services to Medicaid beneficiaries, FQHC/Non-FQHC facilities to provide services to Medicaid beneficiaries, they must be:

  • Under a grant through 42CFR 405.2401.
  • Enrolled with Medicare.
  • Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.

Covered Services

If medically necessary, Kentucky Medicaid will cover:

  • Services and supplies incidental to physician services, nurse practitioner, physician assistant, certified nurse-midwife, clinical psychologist and clinical social worker services;
  • Medicare Part B-covered drugs given incidental to FQHC/Non-FQHC practitioner services;
  • Visiting nurse services to the homebound in areas where the Centers for Medicare and Medicaid Services certifies there is a shortage of home health agencies;
  • Outpatient diabetes self-management training and medical nutrition therapy for patients with diabetes or renal disease;
  • Certain care management services;
  • Certain virtual communication services;
  • Pharmacy services which will meet the coverage criteria established in 907 KAR 23:010
  • Nutritional services provided by a nutritionist;
  • Nurse midwifery services provided as part of a program that includes prenatal services to expectant mothers, delivery or postnatal services.

FQHC/Non-FQHC facilities will provide at least two of the following services: dental services, optometric services or family planning services listed and as limited in 907 KAR 1:048; home health services listed and as limited in 907 KAR 1:030 and social services counseling.

FQHC/Non-FQHC providers must meet the coverage provisions and requirements in 907 KAR 1:054 to provide covered services. Any services performed must fall within the scope of practice for the provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.

Verifying eligibility

To verify eligibility, contact the KYHealth-Net automated voice response system at (800) 807-1301 or use the web-based KYHealth-Net System.

Reimbursement : Reimbursement for FQHC/Non-FQHC services is in accordance with 907 KAR 1:055.

Limitations and exclusions are as follows:

  • If a beneficiary suffers an illness or injury requiring additional diagnosis or treatment or has an encounter with more than one health care provider or multiple encounters with the same health care provider that take place on the same day and at a single location, it will constitute a single visit.
  • A vaccine is available without charge to a child through the Vaccines for Children Program and the administration of the vaccine will not be reported as a cost to the Medicaid Program.
  • Adult flu vaccine costs will be allowed as Medicaid costs reported on a Universal Cost Report.
  • Kentucky Medicaid will not reimburse for services provided by FQHC/Non-FQHC to a beneficiary in a hospital unless the FQHC/Non-FQHC any time prior to the hospital admission provided a service to the beneficiary at its location.

Duplication of Service: Kentucky Medicaid will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the service is covered during the same time period. For example, if a beneficiary is receiving a service from an independent mental health service provider, the department will not reimburse for the same service provided to the same beneficiary during the same time period by an FQHC/Non-FQHC .

Prior Authorizations

CareWise provides prior authorizations for any fee-for-service beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid fee for service claims. Each MCO processes its own claims.

Coding: Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify incidental or mutually exclusive codes. Kentucky Medicaid also uses Correct Procedural Terminology codes and Healthcare Common Procedure Coding system codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of UB-04 billing forms. Providers must bill using the revenue codes listed in the billing manual.

Claim Appeals: Appeal requests made on denied FFS claims must be submitted to Gainwell Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the member's MCO if appealing an MCO claim.

Timely Filing: Claims must be received the longer of either 12 months from the date of service or six months from the Medicare pay date or within 12 months of the last Kentucky Medicaid denial.

Provider Contact Information

If you can't find the information you need or have additional questions, please direct your inquiries to:
Billing Questions - Gainwell Technologies - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance - Gainwell Technologies - (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician-Assisted Drug (PAD) List - Pharmacy Branch - (502) 564-6890

Managed Care Organizations

Aetna Better Health of KY - (855) 300-5528
Anthem Blue Cross Blue Shield - (855) 661-2028
Humana - (855) 852-7005
Passport Health Plan- (800) 578-0775
United HealthCare - (877) 842-3210
WellCare of KY - (877) 389-9457


Report Fraud and Abuse

(800) 372-2970

Regulations

907 KAR- Cabinet for Health and Family Services - DMS Title page

907 KAR 1:054 Coverage provisions and requirements regarding federally-qualified health center services, federally-qualified health center look-alike services and primary care center services

907 KAR 1:055 Payments for the primary care center, federally-qualified health center, federally-qualified health center look-alike and rural health clinic services

907 KAR 3:130 Medical necessity and clinically appropriate determination basis)

Provider Resources

PT (31) - FQHC/Non-FQHC Provider Summary

Search for Provider Letters 

Forms

Map-9: Prior Authorization for Health Services 
MAP-1001501: Prospective Payment System Adjustment Form  and Instructions
MAP- 100601: Scope of Services Survey Baseline Documentations 
Medicaid Universal Cost Report and Instructions
Provider Data for MCO Paid Claims
Supplemental Payment Interim Reconciliation FormAttestation 
and Instructions

Contact Information

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