part ii policies and procedures for rural health clinic services

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(5) A request for review of a change in scope of service must be filed no later than ninety daysafter the close of one year of operation of the service that has changed in scope.(6) A rate adjustment due to a change in scope shall be granted only once for a particularcircumstance for a particular RHC.(7) A request for rate review due to a change in scope of service must be filed in accordance withthe following procedures:(a) The request for review of a change in scope of service must be in writing.(b) The request for a rate review must indicate that it is due to a change in scope ofservice.(c) The request for a rate review must provide a detailed explanation and evidence toprove why a rate adjustment is warranted. The RHC should demonstrate that byproviding either:(i) A community needs assessment shows that population demographic changeswarrant the change in scope of service; or(ii) A business plan or other similar documentation indicates that the new serviceis warranted; and(iii) Efforts were made to address the problem outside of the rate review process.(d) If the request is due to a change in the intensity of services provided, the RHC mustprovide evidence that the intensity of services has changed and that the increased costsare directly related to the change in intensity of service. This evidence might include areport showing that patients‟ diagnoses have changed the acuity of care or a reportproving that the relative values of the services provided has changed.(8) The department shall respond in writing within sixty days of receiving each written requestfor a change in scope of service. If the department requests additional information to determine ifthe rate request is warranted, the department shall respond in writing within sixty days ofreceiving the additional information.(9) If a request for a rate adjustment due to a change in scope of service is granted, thefollowing provisions will apply: (a) The department will review the RHC‟s costs for theservice that has changed in scope and will set a rate based on the reasonable costparameters in Section 1000 of this Manual.(b) The rate increase shall be the difference between the new rates calculated for theservice that has changed in scope minus the rate previously calculated for the prior yearfor that category of service. The rate increase amount shall be added to the current year‟sPPS rate for that specific category of service for the RHC.(c) The rate adjustment shall be effective on the first day of the first full month after thedepartment has granted the request. Retroactive adjustments will not be made.(D) The department‟s decision at the conclusion of the rate review process shall beconsidered final.(E) An RHC must notify the department in writing within ninety days of anypermanent decrease in a scope of service.January 2012 Rural Health Clinic Services I-2
R RRev 01/090402/0902/09APPENDIX JHealth Check Codes Separately Billable at FFS RateInterperiodic Vision Only and Hearing Only Procedure Codes Listed in Health Check Manual AppendixD are separately reimbursable without an encounter visit.Immunization, Tuberculin Skin Test, and Blood Lead Level Screening Procedure Codes Listed in HealthCheck Manual Appendix E are separately Reimbursable with a Health Check encounter visit.January 2012 Rural Health Clinic Services J-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 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 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

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