RHC Coding and Billing Resources

It is important to understand that there are differences in the reimbursement rates for Independent RHCs and Provider-based RHCs:

  1. Medicare Billing and Reimbursement

    1. Noridian Healthcare Solutions
      Noridian acts as the Medicare Administrative Contractor (MAC) for Oregon (and other Western states). They publish a RHC Medicare billing guide for Medicare related billing questions.

    2. CMS Rural Health Clinic Center

      1. Medicare Claims Processing Manual, Chapter 18 – Preventive and Screening Services
      2. Medicare RHC Benefit Policy Manual
      3. Medicare RHC Claims Processing Manual
      4. Medicare Billing guidance for Preventative Services

    3. Helpful Presentations

      1. The Basics of RHC Billing: Health Resources and Services Administration (HRSA)

      2. Rural Health Clinic Billing: Katie Jo Raebel, Wipfli

      3. Billing for RHC and non RHC Services: National Association of Rural Health Clinics (NARHC)

  2. Medicaid (OHP) Billing and Reimbursement

    1. Billing Basics: Oregon Health Authority (OHA) presentation on billing information for all providers who serve Medicaid clients.

    2. FQHC-RHC Provider Guide, 9-1-2012: Two page document with links to resources at the Oregon Health Authority’s Medical Assistance Programs (OHA MAP).

    3. Oregon Medicaid Professional Billing Instructions: includes RHC billing submission process to OHA-MAP.

      1. For reference: OHA-MAP FQHC & RHC Administrative Rulebook

      2. If in doubt of which claim format to use, contact OHA-MAP Provider Services at 800-336-6016 for assistance.

    4. OHA - MAP Training
      OHA-MAP holds a Program Meeting, every two months, specifically for RHCs, FQHCs and Tribal Health Clinics to provide information, updates, and as an opportunity for questions related to Oregon Medicaid. All are welcome. Information is also sent to registered participants. To be added to the announcement list, please contact Jamal Furqan | 503-945-6683 | .

      OHA-MAP Trainer: Jennifer Smith, 503-602-1128.

    5. Oregon Medicaid Prepaid Health Plan Supplemental Payments (“Wraparound”)
      Federal rule requires OHA-MAP to make supplemental payments (“wraparound payments”) to RHCs that contract with Prepaid Health Plans (PHP). The wraparound payment represents the difference, if any, between the payment received by the RHC from the PHP for treating the enrolled patient and the payment to which the RHC would be entitled if they had billed MAP directly for these encounters according to the RHC’s Prospective Payment System (PPS) encounter rate (OAR 410-147-0460). The OHA-MAP Policy Analyst will coordinate this process with each RHC upon enrollment with Oregon Medicaid. Contact: Eric Larson, Fiscal Auditor, , (503)9 45-5991.

    6. Oregon Medicaid and Change-in-Scope: A change in the scope of RHC services may occur if the RHC has added, dropped or expanded any service since initial certification. Please see the Enrolling with Oregon Medicaid page for further details on Oregon Medicaid Change in Scope.