part ii policies and procedures for rural health clinic services

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PART II - CHAPTER 800PRIOR APPROVAL – PRECERTIFICATIONRev 01/09801. “Core” Services RequirementThere are no prior approval requirements in the Rural Health Clinic ServicesProgram. However, clinics should contact the Georgia Health Partnership (GHP)Inquiry line prior to providing services which may not fall within the scope ofprimary care or for which reimbursement is unsure. GHP inquiries may be calledto 1-800-766-4456.The Department may require prior authorization of all or certain procedures basedon the findings or recommendations of the Department, its authorizedrepresentatives or contractual agents. The Commissioner may invoke this actionas an administrative recourse in lieu of or in conjunction with an adverse actiondescribed in Part I, Chapter 400. In such instances, prior notice and justificationshall be served.Rev 01/09802. Instances Requiring Prior Approval or Preadmission CertificationAs a condition of reimbursement, the Department requires that certain services beapproved prior to the time they are rendered. Prior approval from the Departmentpertains to medical necessity only; the patient must be Medicaid-eligible at thetime the service is rendered. If the service is to be performed in an inpatienthospital setting, preadmission certification is required. Selected servicesperformed in an outpatient hospital or ambulatory surgical center (ASC) settingalso require preadmission certification. Preadmission certification does notinclude approval for reimbursement of professional services that require priorapproval.The Department may require prior approval of all or certain procedures performedby a specific physician or group of physicians based on the findings orrecommendations of the Department, its authorized representatives or agents, theSecretary of the U. S. Department of Health and Human Services or the applicableState Examining Board. The Commissioner may invoke this action as anadministrative recourse in lieu of or in conjunction with an adverse actiondescribed in Part I, Chapter 400. In such instances, the Department will serve theprovider with written notice of this requirement and the grounds for such action.January 2012 Rural Health Clinic Services VIII-1
PART II - CHAPTER 900SCOPE OF SERVICES901. RHC ServicesRHC services are those primary care services provided to patients by providerswho are eligible for RHC Provider status as defined earlier in Chapter 700 of thismanual. These services are of the type normally provided as part of a primary carephysician‟s practice and include physician services, services provided byphysician‟s assistants, nurse-midwives and nurse practitioners. In addition, RHCservices include those provided by clinical psychologists, and clinical socialworkers. In areas where there is a shortage of home health agencies, RHC servicesmay also include those services provided to a homebound Medicaid patient by avisiting nurse on a part-time or intermittent basis. The RHC must provide, eitherdirectly or by referral, a full range of these primary diagnostic and therapeuticservices and supplies mentioned above which include but are not limited to:1. Medical history, physical examination, assessment of health status andtreatment of a variety of conditions amenable to medical management on anambulatory basis by a physician or physician extender2. Evaluation and diagnostic services:a. Radiological servicesb. Laboratory and pathology services3. Services and supplies incident to a physician or a physician extender services:a. Pharmaceuticalsb. Supplies4. Visiting nurse services under the criteria described in Section 903.9 of thismanual.901.1 RHC “Core” ServicesRHC “core” services include those services described above in Section901 and those services and supplies incident to these services per Section901.2 below.Rev 01/09For reimbursement purposes, a service visit must be provided in order fora provider to be paid a PPS rate. A visit occurs when one of theprocedure codes listed in Appendix F is billed on a claim. An RHC visitis defined in Appendix C.January 2012 Rural Health Clinic Services IX-1
Page 2 and 3: PART II - POLICIES AND PROCEDURESFO
Page 4 and 5: Rev. 01/09APPENDIX AAPPENDIX BAPPEN
Page 6: . 01/09Rev. 01/09Rev. 01/09Rev. 07/
Page 12 and 13: Rev 01/09Payments specified as the
Page 14 and 15: 902.1 ICD-9-CMCodes deleted from pr
Page 16 and 17: 903.3 Laboratory ServicesRev 01/09R
Page 18 and 19: COS 600 ID. The procedure codes for
Page 20 and 21: 904 Other Ambulatory Clinics Servic
Page 22 and 23: 4. ResidentialRev 01/09Clinics may
Page 24 and 25: 1001. Reimbursement MethodologyPART
Page 26 and 27: health clinics, and the UB-04 claim
Page 28 and 29: APPENDIX BSTATEMENT OF PARTICIPATIO
Page 30 and 31: Rev 01/09Rev 01/09Rev 01/09Example
Page 32 and 33: APPENDIX EBILLING INSTRUCTIONS AND
Page 34 and 35: PLACE OF SERVICE CODES11 - Office12
Page 36 and 37: Completion of the Health Insurance
Page 38 and 39: OrEnter the Prior Authorization Num
Page 40 and 41: enter the date.Unsigned invoice for
Page 42 and 43: Completion of the National Uniform
Page 44 and 45: FL 42FL 43FL 44FL 46FL 47Revenue Co
Page 46 and 47: FL 68thru 75Codes prefixed in „E
Page 48 and 49: Established Patient 99391 - 99395Ne
Page 50 and 51: APPENDIX HVACCINE FOR CHILDREN PROG
Page 52 and 53: (5) A request for review of a chang

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