part ii policies and procedures for rural health clinic services

Rev 01/09Rev 01/091001.2 Changes in Scope of ServicesA change in scope of services for a RHC is defined as a change in thetype, intensity, duration and/or amount of services. It is the clinic‟sresponsibility to recognize any changes in their scope of services and tonotify the Department of those changes and to provide the Departmentwith documentation and projections of the cost and volume impact of thechange. (See Appendix I)1001.3 RHC contracting with Care Management Organizations (CMO)When an RHC provides services listed in Appendix G pursuant to acontract between the clinic and a Care Management Organization (asdefined in Social Security Act section 1932(a)(1)(B)), the State shallperform a reconciliation at least annually, or more often if the Statedetermines it is necessary, to ensure that CMO payment equivalent to theamount calculated under the PPS rate. The State shall provide asupplemental payment (only the portion, if any, that State is responsiblebased on the contract between the department and CMO) equal to theamount by which the PPS rate exceeds the amount of the paymentsprovided by the CMO on an aggregate annual base. Any suchsupplemental payments shall be made pursuant to a payment schedule offour months or more agreed to by the State and the clinic.Rev 01/091001.4 Alternative Payment MethodologyAn alternative payment methodology is established for servicesfurnished in Rural Health Clinics located at Critical Access Hospitals.The reimbursement methodology will follow the provisions establishedin the State Plan. All clinics affected by this methodology have agreedthat their payments will at least equal the amount they would havereceived under the PPS methodology.1001.5 Cost ReportsRev 01/09January 1, 2001 The Benefits Improvement and Protection Act (BIPA) of2000 eliminated the requirement for the submission of annual cost report.However, if the Department determines it has a continued need for costreports or other accounting methods, it has the flexibility to require suchreports.1001.6 Members with Medicaid OnlyThe appropriate claim form for reimbursement of Rural Health ClinicServices provided to patients covered only by Medicaid is thePhysician/or Other Service Invoice (CMS-1500) for freestanding ruralJanuary 2012 Rural Health Clinic Services X-2