Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

D. Frequently Asked Questions (con’t)
law or state regulatory mechanism governing PA, NP or CNM practice.
Q: What is the per visit upper payment limit for RHCs for 2008
A: For CY 2008, the Medicare RHC upper payment limit per visit is $75.63. Provider-based clinics
that are owned by a hospital with less than 50 beds are exempt from this per visit reimbursement
cap. For more information, visit the Centers for Medicare and Medicaid Services at: www.
cms.hhs.gov .
Q: How does Medicare reimburse RHCs
A: Certified Rural Health Clinics receive an interim payment rate throughout the clinic’s fiscal
year, which is reconciled at the end of the fiscal year through cost reporting. The interim payment
rate is determined by taking total allowable costs for RHC services divided by allowable visits
provided to RHC patients receiving core RHC services. RHC staff should understand traditional
Medicare regulations for coding and documentation as well as unique RHC billing requirements.
Q: How does Arizona reimburse RHCs for Medicaid
A: AHCCCS, Arizona’s Medicaid program, recognizes RHC services. The state reimburses RHCs
under one of two different methodologies. The first is a prospective payment system. Under this
methodology, for fiscal year 2001, the state calculated a per encounter rate based on an average of
100 percent of the reasonable costs furnished in FY 1999 and FY 2000. For each succeeding year,
this per encounter baseline rate is then increased by the Medicare Economic Index factor. The
second rate setting methodology (the Alternative Payment Methodology) requires a rebase of the
PPS rate every three years, and the physician services component of the CPI is used to inflate the
rate during the interim years. The clinic must agree to this methodology, and the payment to the
clinic must at least equal the payment under a prospective payment system.
The Arizona reimbursement methodology can be downloaded at:
http://www.azahcccs.gov/PlansProviders/FQHC_RHC/FQHC_RHC.asp
Q: How is an RHC encounter defined
A: An encounter is defined as a face-to to-face visit between a recognized provider (i.e., physician,
PA, NP, CNM, or mental health provider) and a Medicare beneficiary for a medically necessary
reason. Clinics receive the RHC rate for Medicare patients for every encounter.
Q: What is the difference between a UPIN and a PIN
A UPIN (Unique Provider Identification Number) is a six-character alphanumeric identifier assigned
to all Medicare physicians, medical groups and non-physician practitioners. A PIN (Provider
Identification Number) is a unique number issued by payers to each provider to identify that
provider as a credentialed and approved provider. This number is also known as a Medicare billing
number.
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