part ii policies and procedures for rural health clinic services

APPENDIX DCOPAYMENTRev 7/04Effective with dates of service July 1, 1994, and after, a $2.00 member co-payment is required onall Rural Health Clinic Services (RHC). The $2.00 co-payment will be deducted from thecenter‟s “All-Inclusive” rate when payment is made.The co-payment does not apply to the following members:Pregnant womenMembers under 21 years of ageNursing facility residentsHospice care membersWomen diagnosed with breast or cervical cancer and receiving Medicaid under theWomen‟s Health Medicaid Program, aid categories 245 and 800, only.The co-payment does not apply to the following services:Emergency services (See Appendix F Hospital Manual as Educational Guideline;procedure codes range from 99281-99285)Family Planning servicesThe provider may not deny services to any eligible Medicaid member because of the member‟sinability to pay the co-payment.The department may not be able to identify all members who are exempt from the co-payment.Therefore providers should identify the members as documented below:To identify members receiving Family Planning services enter “FP” in item 24H on theCMS-1500 claim form and “A4” in the condition code field (FL 24) on the UB- 92 claimform.GHP will automatically deduct the co-payment amount from the provider‟s payment for claimsprocessed with dates of service July 1, 1994, and after. Do not deduct the co-payment from yoursubmitted charges. The application of the co-payment will be identified on the remittance advice.A new explanation of benefit (EOB) code will indicate payment has been reduced due to theapplication of co-payment.January 2012 Rural Health Clinic Services D-1