RHC Financial and Operational Improvement

RHC Billing and Coding Resources

Medicaid/Oregon Health Plan (OHP) Billing Reimbursement

1. Billing Basics: Oregon Health Authority (OHA) presentation on billing information for all providers who serve Medicaid clients.
2. FQHC-RHC Provider Guide: Two page document with links to resources at the Oregon Health Authority’s Medical Assistance Programs (OHA MAP). FQRC-RHC Program page.
3. Oregon Medicaid Professional Billing Instructions: includes RHC billing submission process to OHA MAP.
   1. For current Oregon Administrative RHC Rules refer to: OHA Health System Division: Medical Assistance Programs- Chapter 410
   2. If in doubt of which claim format to use, contact OHA MAP Provider Services | 800-336-6016 | for assistance.
4. 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 | 503-945-5991.
5. 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 410-147 [0362] Change in Scope of Services for further details on Oregon Medicaid Change in Scope.

Medicare Billing and Reimbursement

1. Noridian Healthcare Solutions
   Noridian acts as the Medicare Administrative Contractor (MAC) for Oregon and other Western states. They publish an 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
   5. Provider Wraparound Data Template | Note: Both the “Cover Page” and “Raw Data” tabs must be completed for submissions.
3. Helpful Presentations
   1. Basic RHC Billing v. 2020:  Charles James, Jr. North American HMS
   2. Advanced RHC Billing and Coding v.2020 Charles James, Jr North American HMS

Webinars

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Contact

Rondyann Gerst | 503-312-3907