part ii policies and procedures for rural health clinic services

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enter the date.Unsigned invoice forms cannot be accepted for processing.Item 32Name and Address of Facility Where Services RenderedEnter the full name, location (city) of the facility where billed services wereperformed.Item 33 Physician‟s Supplier‟s Billing Name. Address. Zip Code and Phone #Enter the provider‟s name and address. Providers must notify the GHP ProviderEnrollment Unit in writing of address changes.PIN NumberEnter the NPI number in field 33A.Enter the identifying Medicaid Provider number assigned to you in field 33B.NOTE:Reimbursement for Rural Health Clinic Services is based on an actual clinicencounter or visit (office, emergency room or hospital) even though other servicesare rendered at the same time. Rural Health Clinic Services are reimbursedaccording to the clinics assigned “all inclusive” rate. Please refer to Appendix Cof this manual for clinic encounter explanation.Mail Claims To:HP Enterprise ServicesCMS 1500 ClaimsP.O. Box 105202Tucker, GA 30085-5202January 2012Rural Health Clinic Services E-9
Figure 2. UB-04 FormJanuary 2012 Rural Health Clinic Services E-10
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 10 and 11: PART II - CHAPTER 800PRIOR APPROVAL
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 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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