Official State of Rhode Island website

The Executive Office of Health and Human Services State of Rhode Island

Federally Qualified Health Centers

Provider Representative: Andrea Rohrer   Tel. (469)-897-4389
                                               email: andrea.rohrer@gainwelltechnologies.com

Reference Materials 

- Principles for Reimbursement for Federally Qualified Health Centers -SFY 2022

Updates

FQHC Billing Guidance
The FQHC policy states under the Principles of Reimbursement that when a member is seen by more than one (1) professional on the same date of service, the visits are considered one (1) encounter, unless:

  • One visit is medical and the other is behavioral health, or
  • One visit is medical and the other is dental, or
  • The member presents with an additional or different illness that requires a separate visit.

Each visit must be clearly documented in the member’s medical record and must meet commonly accepted standards of medical record documentation. As a reminder, only one (1) encounter is allowed per member, per day, per service.

This policy applies regardless of claim type, including professional, professional crossover, or dental claims. Submission of multiple encounters for the same member, same service (Medical, Behavioral, or Dental), on the same date of service may result in claim denials.

FQHCs Dental Providers
If a CDT code requires prior authorization for the service. FQHCs will need to submit a prior authorization (PA) even if the CDT code is an informational code on the claim.  Please review the dental provider manual for codes requiring PA: RI Medicaid Dental Provider Manual.

You can either use the standardized PA form or the ADA 2012/2019 form to submit your PA requests to RI Medicaid.
Prior authorization requests can either be submitted by:
Mail to Gainwell Technologies PO Box 2010 Warwick, RI 02887
Faxed to 401-784-3892
 

Equality in Abortion Coverage Act (EACA)
The Equality in Abortion Coverage Act (EACA) was signed into law by the State of Rhode Island on May 18, 2023. Under the law, the EACA will provide insurance coverage for abortion care to individuals on Medicaid to increase access and reduce financial limitations of reproductive health care at the state level. The legislation (2023-S 0032, 2023-H 5006) eliminates sections of the law that expressly prohibit the state’s Medicaid programs from covering any abortion, except in cases of rape or incest or when the completion of the pregnancy would be life-threatening.

Historically, reimbursement for an abortion required providers to submit a form documenting that the reason for the abortion was rape or incest or because completion of the pregnancy would be life-threatening. In the event, that one of these conditions applies, providers should continue to follow that process. 

To be paid for abortions newly eligible for payment under the EACA, FQHC’s should bill the applicable abortion CPT code with the modifier FP (SERVICE PROVIDED AS PART OF MEDICAID FAMILY PLANNING).  Claims billed without the new FP modifier will continue to deny unless accompanied by the required form described above.

The abortion service claim with the FP modifier should be billed as a separate claim from the Encounter (T1015) claim.

Effective for dates of service on or after May 18, 2023, the following CPT codes can be billed with the FP modifier:

  • 59840-FP         59841-FP         59850-FP
  • 59851-FP         59852-FP         59855-FP
  • 59856-FP         59857-FP         59866-FP
  • S0190-FP         S0191-FP         S0199-FP


If you have claims for dates of service over a year old, please submit those claims on a signed (Box 31) paper CMS 1500 claim form to the attention of your Provider Representative, Andrea Rohrer. Claims should be mailed to the address below and must be received by Monday September 30, 2024.  

For questions please contact Andrea Rohrer at andrea.rohrer@gainwelltechnologies.com or (469) 897-4389. 

The mailing address for claims over a year old is:

Gainwell Technologies
PO Box 2010
Warwick, RI 02887-2010
Attn:  Andrea Rohrer

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