Oregon Office of Rural Health

Rural and Frontier Clinics

Ecola State Park

Rural Clinic Types

A medical clinic located in a rural or frontier area, but not certified — either as part of the Centers for Medicare and Medicaid Services (CMS) and Health Resources and Services Administration (HRSA) Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) programming. Non-certified clinics may apply to become RHCs or FQHCs, based on meeting organizational, operational and programming criteria. A clinic may not hold concurrent certifications; an RHC cannot simultaneously be an FQHC, and vice-versa.

The RHC program was established by Public Law 95-210, the Rural Health Clinic Service Act, in 1977 to increase primary care services for Medicaid and Medicare patients in rural communities. RHCs receive special Medicare and Medicaid rates, depending on the type of services that the clinic provides and the payer mix of the patient population. RHCs may operate as public, private, or non-profit entities. The national organizing body for RHCs is the National Association of Rural Health Clinics (NARHC).

Static map | Interactive map | Directory

Federally Qualified Health Centers (also called Community Health Centers) were created under Medicare in 1991 when Section 1861(aa) of the Social Security act was amended by Section 4161 of the Omnibus Budget Reconciliation Act. FQHCs are safety net providers that primarily provide outpatient services. FQHCs may be rural or urban and may be operated by a tribe. In Oregon, the organizing body for FQHCs is the Oregon Primary Care Association (OPCA).

Eleven of Oregon’s tribal health clinics are located in ORH-defined rural or frontier areas. These clinics are not certified RHCs. All of Oregon’s tribal clinics are provided direction and oversight by the Northwest Portland Area Indian Health Board.

Map | Directory

Technical Assistance and Resources

How Can I Help You? Creating an Awesome Patient Experience Every Time

Patient Experience Webinar
June 22, 2021

2 p.m. to 3 p.m.

Presented by Lauren K. Harris, FACMPE
Harris Healthcare Consulting, LLC
Partnering with practices to identify and achieve their goals

Join Lauren for a practical and informative webinar full of tools you can start using the same day to improve your customer service skills and create exceptional experiences for your patients every time.                                                                                         

  • Learning points:
  • What is customer service and why does it matter?
  • What is your role in the patient experience?
  • Specific and actionable goals for your patient interactions
  • Skills and behaviors of customer service experts
  • How to respond to a dissatisfied patient
  • Sample scripts and more!

Lauren is passionate about medical practices and enjoys partnering with them to see them succeed. After years of honing her skills within large and small organizations of multiple specialties, including RHC and School-Based Health Centers, she started her own consulting practice in July 2020. She partners directly with practitioners and leaders to provide business and operation expertise.  Lauren started her healthcare management career in 1992, and achieved her MGMA/CMPE certification in 2008 and her FACMPE certification in 2013.

Please contact Rondyann Gerst with any questions.

RHC Regulatory & Operational Update

May 12, 2021
Presented by Katie Jo Raebel, CPA, and Partner at Wipfli

This webinar will cover legislative changes, the issues and risks regarding the unknowns, as well as strategies that RHCs should be considering to optimize reimbursement.

Learning Objectives

  • Evaluate strategies for managing under the new RHC reimbursement limitations
  • Discuss HHS CARES Act provider fund reporting & documentation requirements

Katie Jo Raebel has more than 19 years of experience in audit and accounting services, focused exclusively on health care industry clients. She specializes in assisting freestanding and provider-based clinics to navigate through the rural health clinic (RHC) certification process and is a proven thought leader with vast experience in the RHC arena. Katie Jo helps to calculate RHCs’ Medicare and Medicaid rates, provides education regarding changes in billing because of certification, and consults on all areas specific to RHCs. In addition, she helps organizations determine the best certification options to experience the most beneficial gain from Medicare and Medicaid reimbursement.
Katie Jo is a regular speaker at industry events and conferences including the Rural Health Clinic Association of Washington, the Oregon Rural Health Conference, the National Association of Rural Health Clinics Conference, and most recently the Idaho Department of Health and Welfare’s Bureau of Rural Health and Primary Care annual conference. She also is a featured speaker at the annual Spokane office-sponsored cost report and reimbursement seminar.

Video and slides

How to Be Your Own Consultant

Leadership Development Workshop Webinar Series
March 18, 2021

Presented by Lauren K. Harris, FACMPE
Harris Healthcare Consulting, LLC

Partnering with practices to identify and achieve their goals- Lauren is passionate about medical practices and enjoys partnering with them to see them succeed. After years of honing her skills within large and small organizations of multiple specialties, including RHC and School-Based Health Centers, she started her own consulting practice in July 2020. She partners directly with practitioners and leaders to provide business and operation expertise. Lauren started her healthcare management career in 1992, and achieved her MGMA/CMPE certification in 2008 and her FACMPE certification in 2013.

Video & slides

Resilience, Relationships, Compassion and COVID

Leadership Development Workshop Webinar Series
March 11, 2021

Presented by Lauren K. Harris, FACMPE
Harris Healthcare Consulting, LLC

Partnering with practices to identify and achieve their goals- Lauren is passionate about medical practices and enjoys partnering with them to see them succeed. After years of honing her skills within large and small organizations of multiple specialties, including RHC and School-Based Health Centers, she started her own consulting practice in July 2020. She partners directly with practitioners and leaders to provide business and operation expertise. Lauren started her healthcare management career in 1992, and achieved her MGMA/CMPE certification in 2008 and her FACMPE certification in 2013.

  • Identify what resilience is and how to practice it
  • Understand the value of work relationships and how to create and build them
  • Learn techniques for knowing and taking care of ourselves
  • Understand what compassion is and how to practice it with ourselves and others

Video & slides

Employee Engagement and Teambuilding

Leadership Development Workshop Webinar Series
February 25, 2021

Presented by Lauren K. Harris, FACMPE
Harris Healthcare Consulting, LLC

Partnering with practices to identify and achieve their goals- Lauren is passionate about medical practices and enjoys partnering with them to see them succeed. After years of honing her skills within large and small organizations of multiple specialties, including RHC and School-Based Health Centers, she started her own consulting practice in July 2020. She partners directly with practitioners and leaders to provide business and operation expertise.  Lauren started her healthcare management career in 1992, and achieved her MGMA/CMPE certification in 2008 and her FACMPE certification in 2013.

Video & slides

Survey Readiness During the Public Health Emergency (PHE)

February 23, 2021
Presented by Kate Hill, RN, VP of Clinical Services
The Compliance Team

Kate Hill, RN, is a graduate of Einstein Medical Center School of Nursing.  As an Army Nurse, Kate served in Viet Nam where she was awarded the Bronze Star.  Kate has worked with orthopedic patients in several capacities including nearly 3-decades with Biomet. Kate joined The Compliance Team in early 2012 to direct TCT’s rural health clinic accreditation program and has fallen in love with Rural. As VP of Clinical Services, she has spearheaded TCT’s Rural Health Clinic Accreditation program combining her clinical expertise, business acumen and passion for delivery of the best care possible to every patient.

Video & slides

How to Develop from Manager into Leader

Leadership Development Workshop Webinar Series
February 11, 2021

Presented by Lauren K. Harris, FACMPE
Harris Healthcare Consulting, LLC

Partnering with practices to identify and achieve their goals- Lauren is passionate about medical practices and enjoys partnering with them to see them succeed. After years of honing her skills within large and small organizations of multiple specialties, including RHC and School-Based Health Centers, she started her own consulting practice in July 2020. She partners directly with practitioners and leaders to provide business and operation expertise.  Lauren started her healthcare management career in 1992, and achieved her MGMA/CMPE certification in 2008 and her FACMPE certification in 2013.

Video & slides

Advanced RHC Cost Reporting

February 10, 2021
Presented by Katie Jo Raebel, CPA and Partner
Wipfli, LLP

This session will build off of information gained from the Basic RHC Cost Reporting presentation. We will focus on advanced topics related to Medicare RHC cost reporting and common cost reporting inaccuracies and opportunities for improvement.

Learning Objectives

  1. Understand how productivity standards may affect your cost-per-visit calculation and payments from other payers
  2. Compare your clinic’s key cost report information to those in Oregon and throughout the nation
  3. Strategize reimbursement optimization while ensuring reporting accuracies

Katie Jo Raebel has more than 19 years of experience in audit and accounting services, focused exclusively on health care industry clients. She specializes in assisting freestanding and provider-based clinics to navigate through the rural health clinic (RHC) certification process and is a proven thought leader with vast experience in the RHC arena. Katie Jo helps to calculate RHCs’ Medicare and Medicaid rates, provides education regarding changes in billing because of certification, and consults on all areas specific to RHCs. In addition, she helps organizations determine the best certification options to experience the most beneficial gain from Medicare and Medicaid reimbursement.
Katie Jo is a regular speaker at industry events and conferences including the Rural Health Clinic Association of Washington, the Oregon Rural Health Conference, the National Association of Rural Health Clinics Conference, and most recently the Idaho Department of Health and Welfare’s Bureau of Rural Health and Primary Care annual conference. She also is a featured speaker at the annual Spokane office-sponsored cost report and reimbursement seminar.

Video & slides

Basic RHC Cost Reporting

February 3,2021
Presented by Katie Jo Raebel, CPA and Partner
Wipfli, LLP

This session will provide an overview of the rural health clinic Medicare cost report. Join us as we analyze each worksheet within this report (CMS Form 222-17) in order to gain an overall understanding of the basic functions of the Medicare cost report.

Learning Objectives

  1. Understand the various worksheets of the Medicare cost report, the flow of information, and where to find valuable data.
  2. Review the three components of the Medicare cost report settlement, the calculation of those amounts, and how the information provided to your cost report preparer can affect the final receivable/payable.
  3. Learn best practices for tracking information during the year in order to ensure an accurate report.

Video & slides

Planning and Goal Setting for 2021

Leadership Development Workshop Webinar Series
January 28, 2021

Presented by Lauren K. Harris, FACMPE
Harris Healthcare Consulting, LLC

Partnering with practices to identify and achieve their goals- Lauren is passionate about medical practices and enjoys partnering with them to see them succeed. After years of honing her skills within large and small organizations of multiple specialties, including RHC and School-Based Health Centers, she started her own consulting practice in July 2020. She partners directly with practitioners and leaders to provide business and operation expertise.  Lauren started her healthcare management career in 1992, and achieved her MGMA/CMPE certification in 2008 and her FACMPE certification in 2013.

Video & slides

RHC, What Now After COVID-19?

January 21,2021
Presented by Kate Hill, RN, VP of Clinical Services
The Compliance Team

During this webinar, Kate will discuss how to manage compliance in the clinic during the ongoing Public Health Emergency. How to complete the Emergency Preparedness After Action Report (AAR). The importance of infection prevention in the clinic now and moving forward. How things are different now in the RHC and for the foreseeable future. The issue of staying compliant when staff is lighter than usual.

Kate Hill, RN, is a graduate of Einstein Medical Center School of Nursing.  As an Army Nurse, Kate served in Viet Nam where she was awarded the Bronze Star.  Kate has worked with orthopedic patients in several capacities including nearly 3-decades with Biomet. Kate joined The Compliance Team in early 2012 to direct TCT’s rural health clinic accreditation program and has fallen in love with Rural. As VP of Clinical Services, she has spearheaded TCT’s Rural Health Clinic Accreditation program combining her clinical expertise, business acumen and passion for delivery of the best care possible to every patient.  She presently serves on the Board of the National Association of Rural Health Clinics and on the Congress at NRHA. She feels fortunate to speak at numerous state and national meetings about RHC compliance countrywide, which gives her the opportunity to learn firsthand the diverse issues clinics are facing.  Kate lives in suburban Philadelphia with her husband and near her three granddaughters.

Video & slides

Critical Maintenance Emergency Plan Biennial Review, Civil Rights, Personnel File Audits

January 6, 2021
Presented by Tressa Sacrey, RHC Compliance Analyst
Health Services Associates
 
Tressa R. Sacrey joined Health Services Associates in May 2015 as a Compliance Analyst. Mrs. Sacrey has a Bachelor’s Degree in Education and has completed courses in Business Applied Technology. Key areas of responsibility include creating policies, developing emergency plans, facilitating hazard training, researching CMS regulations, conducting on-site compliance mock surveys, and creating forms and tools to assist RHC’s across the nation.
 
Tressa will discuss how maintaining compliance at the RHC is an ongoing process.
 
Participants will:

  • Gain an understanding of the required civil rights elements for the clinic
  • Discover which documents will be reviewed during the personnel file audit
  • Learn the operative guidelines and timeframes for the emergency plan review

 
You won’t want to miss this valuable training!
Stay ready for your next survey.
Be operationally sound, so you can stay focused on what matters most - The Patient!

Video & slides

RHC Survey During COVID-19: Q&A with Janis McDowell, State Surveyor

December 11, 2020

Please come prepared to ask questions about RHC surveys during the COVID-19 PHE and learn how you can prepare for an unannounced survey.
Join us as we explore:

  • How the survey has changed during COVID-19
  • The challenges of a survey during the PHE
  • What is involved in the COVID-19 Focused Infection Prevention Survey

Janis McDowell, RN, BSN, MA, is a Patient Safety Surveyor for OHA’s Health Facility Licensing and Certification Office with almost 5 years’ experience surveying hospitals, home health agencies, ambulatory surgery centers with current focus on dialysis centers and rural health clinics. Before moving into the realm of regulatory work, Janis’ nursing experience included trauma recovery and mental health.

Video

2021 E/M Coding and Billing Changes

December 9, 2020

Presented by Kim Huey, KGG Coding and Reimbursement Consulting, LLC

During this webinar Kim will walk you through everything you need to successfully implement the 2021 CPT code changes in your RHC.  

This webinar will cover:

  • 2021 overview of ICD-10 and CPT coding and billing changes;
  • Documentation updates to support the new codes;
  • CMS changes for E/M and coding reimbursement; and
  • How fraud and abuse will affect these changes, and more.

Information was accurate as of the date of the presentation.

Video & slides

Rural Telehealth: What is the impact to RHCs during the PHE and beyond?

August 12, 2020

Not only has the COVID-19 PHE changed the way the we do business in our rural healthcare facilities, it has also changed the way that we have used telehealth in providing patient care.  Join us as we explore:

  • How the provision of telehealth services has changed during the COVID-19 PHE
  • The challenges of providing telehealth during the PHE
  • How the PHE may change the telehealth landscape in the future

Video & slides

Advanced RHC Billing and Coding

June 6, 2020

Advanced Rural Health Clinic Billing and Coding webinar takes a deeper look at RHC services and how to report them. It reviews in-depth claim examples based on a variety of patient visit scenarios. These include: RHC telehealth billing, mental health billing, specialists in the RHC, preventive services, care management services, and negative payments.

Video & slides

Basic RHC Billing and Coding

June 6, 2020

The Basic Rural Health Clinic Billing and Coding webinar reviews RHC services and how to report them. It includes all of the basics for building and reporting RHC Medicare claims. It covers RHC locations and providers, incident to, surgeries, injections, RHC services vs. non-RHC services, specialists and global billing.

Video & slides

Rural Health Clinic COVID-19 Listening Session #3

April 23, 2020

RHC leaders have a roundtable discussion regarding operating in the present environment amid COVID-19.

Video & slides

RHC Emergency Preparedness, Part 2

April 22, 2020

Kate Hill from The Compliance Team discusses RHC Emergency Preparedness Training and Testing with an example of a Table Top Drill and After Action Report (AAR).

Video & slides

Rural Health Clinic COVID-19 Listening Session 2

April 9, 2020

RHC leaders discuss concerns and challenges internally and in their community.

Video & slides

RHC Emergency Preparedness and COVID-19, Part 1

April 8, 2020

Kate Hill from The Compliance Team discusses RHC COVID-19 strategies to use in your clinic and requirements of RHC Emergency Preparedness 42 CFR 491.12.

Video & slides

Telehealth for Oregon Rural Health Clinics: Resources and Reimbursement

April 7, 2020

Rose Locklear (Oregon Office of Rural Health) and Tammy Norville (National Organization of State Offices of Rural Health) walk you through a new resource created to help you navigate the policy and resources related to telehealth amid the COVID-19 crisis.

Video & slides

Rural Health Clinic COVID-19 Listening Session 1

March 26, 2020

RHC leaders discuss top concerns which include: supplies, testing, community, policies and procedures, amid COVID-19 pandemic.

Video & slides

RHC Compliance 101, Part 2

January 15, 2020

Kate Hill from The Compliance Team, goes into more detail regarding compliance requirements in Rural Health Clinics.

Video & slides

RHC Compliance 101, Part 1

January 8, 2020

Kate Hill from The Compliance Team, covers compliance requirements in Rural Health Clinics form completion through survey.

Video & slides

These resources should be considered general and preliminary only. Final determination of rural status will be made by the State of Oregon. Please contact Janice McDowell, RN | janis.s.mcdowell@state.or.us971-673-3269 at Health Care Regulation and Quality Improvement (HCRQI) for final determination.

Does the clinic qualify as a rural site?

  1. The clinic is not in a Census Urbanized Area:
    1. Map of Census Urbanized Areas
    2. U.S. Department of Health and Human Services (HHS) Rural Health Information Hub’s Am I Rural? tool provides a custom report of rural status by address.
  2. The clinic is in a current Health Professions Shortage Area (HPSA) or a Medically Underserved Area (MUA) issued or renewed within the previous four years.

    HPSA: The age of the designation is calculated as the last day of the year 4 years from the date of the original designation, or the date the area was last designated. For example, a clinic that is located in an area that was most recently designated or updated on June 1, 2010, would be considered as meeting this location requirement through December 31, 2014. In Oregon, HPSA scores are updated every three years by the Oregon Health Authority’s Primary Care Office. To ensure your area’s HPSA score has not expired, contact:  PCO.Oregon@state.or.us | 503-373-1779.

    MUA: MUAs do not expire however if you are using an MUA for RHC purposes, and do not have a HPSA. The MUA designation must have been issued within the past four years.

    1. Compare site against maps and lists of Oregon HPSAs and MUAs
    2. Search HPSA & MUA by address

Is there a financial benefit to RHC status for the clinic?

RHCs (and FQHCs) receive special Medicare and Medicaid reimbursement rates for the care they provide. The RHC rate benefit can vary from clinic to clinic depending on the type of services that the clinic provides and the payer mix of the patient population.

Options:

  1. As an introductory resource, a basic Medicare-focused financial analysis worksheet is available in Starting a Rural Health Clinic, Appendix F.
  2. ORH can assist you with a more detailed Medicare and Medicaid financial impact analysis of your current Fee-for-Service rates vs. current RHC rates. Please contact: Rondyann Gerst | gerst@ohsu.edu | 503-312-3907.
  3. Wipfli LLP can provide various services to clinics considering RHC status.

Does the clinic meet RHC personnel requirements?

More than 50% of the clinic’s services must be Primary Care: Family Care, Internal Medicine, OB/GYN, and Pediatrics. An RHC must:

  1. Employ a Nurse Practitioner (NP) or Physician Assistant (PA)

    RHCs may contract with NPs, PAs, Certified Nurse Midwives (CNM), Clinical Psychologists (CP), and Clinical Social Workers (CSW) when at least one NP or PA is employed by the RHC.

  2. Have an NP, PA, or CNM (employee + contract) working at the clinic at least 50 percent of the time the clinic operates.

The Health Care Regulation and Quality Improvement (HCRQI) Section of the Oregon Health Authority (OHA) has an agreement with the Center for Medicare and Medicaid Services (CMS), to assist in determining whether health care facilities meet, and continue to meet, required conditions of participation. Questions about the application and survey may be directed to Janice McDowell, RN | HCRQI | 971-673-3269 | janis.s.mcdowell@state.or.us.

Complete and return the following forms to:

HCRQI Program | FAX: 971-673-0556

  • Health Insurance Benefit Agreement:  HCFA 1561 A (two signed originals required)
  • Request to Establish Eligibility:  HCFA 29
  • The following is also required for Provider-based RHCs:

    New applicants for Medicare funding and current providers undergoing a change of ownership are responsible for submitting an Assurance of Compliance (HHS-690) attesting that they will comply with all applicable civil rights laws enforceable by OCR (Title VI, Section 504, Title IX, the Age Discrimination Act, and Section 1557).

    As of September 1, 2016, OCR is accepting the HHS-690 only via the online Assurance of Compliance portal. Upon submission of the HHS-690, the providers will receive a notification that the document has been successfully submitted. Clinics should print out and include the confirmation as part of their application packet. The providers are responsible for notifying CMS and/or the state survey agency.

Complete the Medicare Enrollment Application

This must be completed and approved prior to scheduling a survey. The initial enrollment fee is currently $569 – see PECOS online payment.

Two options:

  1. Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) may be used for faster processing time and online payment.

    Or

  2. Forms CMS-588 and CMS-855A may be downloaded and submitted to Noridian, the Oregon regional Medicare Administrative Contractor (MAC).

Once the HCRQI program office has received approval of the application CMS-855A from Noridian, a written request should be submitted to the HCRQI Program for a survey of the clinic. All forms must be complete, signed and submitted prior to scheduling the survey. Please note:  this will be an unannounced onsite survey. It is very important to carefully and adequately prepare for the RHC accreditation inspection. Failure of this inspection can substantially delay certification of the clinic for RHC status. In addition, if the clinic should fail the initial HCRQI inspection, it will be required to hire a private contractor for a follow-up certification inspection. To assure that a clinic meets certification inspection criteria, they will need to:

  1. Develop an RHC Policy and Procedure Manual (a sample manual is available in Appendix D of the Starting a Rural Health Clinic – A How-To Manual, or Provider- based clinics may use this template.
  2. Ensure clinic lab services are in place and licensed – CLIA Application

    Contact: The Oregon Laboratory Compliance Section | 503-693-4126.

    The clinic must have the ability to perform the following lab procedures onsite:

    • Chemical examination of urine by stick or tablet method or both
    • Hemoglobin or hematocrit
    • Blood sugar
    • Examination of stool specimens for occult blood
    • Pregnancy tests
    • Primary culturing for transmittal to a certified laboratory

Ensure that the clinic meets all conditions of certification that the HCRQI survey staff are directed to assess:

  1. Review CMS rules to surveyors
  2. Review the survey preparation checklist . The ORH RHC Program Manager will assist you in preparing for the survey.
  3. Conduct practice inspections:
    • ORH can arrange to perform a technical assistance site inspection of a clinic to identify areas of improvement necessary prior to the official HCRQI Program survey. Please contact Rondyann Gerst | gerst@ohsu.edu | 503-312-3907.
    • If a clinic plans to conduct practice inspections independently, a detailed survey preparation checklist, created by ORH and Wipfli, is available. The checklist details the specific items of focus needed to meet Federal RHC certification.

Alternative Vendor Certification options:  potentially faster alternative accreditation options are available for clinics that are willing/able to pay.  Two companies, American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAASF) and The Compliance Team, are authorized by the CMS to offer certification services.

For information on Medicaid in Oregon, refer to the Oregon Health Authority Division of Medical Assistance Programs Oregon Administrative Rules.

Provider Enrollment

  1. Complete the following RHC enrollment forms: OHP 3104OHA 3972OHA 3974, and OHA 3975. Available at: OHP Provider Enrollment.
  2. Include:
  3. Submit all of the above to the OHA Medical Assistance Program (MAP): Jennifer Smith | 503-602-1128 | Jennifer.R.Smith@state.or.us .

RHC Rate Calculation and Increases

Initial RHC Rate Determination

The Medicare Cost Report informs the RHC rate calculation, which will set the clinic’s Medicaid RHC encounter rate. This rate is adjusted annually based on the Medicare Economic Index (MEI). The RHC will be enrolled with Oregon Medicaid on the date the PPS encounter rate is determined.

Oregon Medicaid Change in Scope

A change in the scope of RHC services may occur if the RHC has added, dropped or expanded any service that meets the definition of an RHC service. Full details at OAR 410-147 [0362]. If there is a change in scope which significantly changes the cost of services, a change of scope may be requested in order to qualify for a readjusted rate.

  1. Submit a narrative outlining the proposed qualifying events for a change in scope to the OHA-MAP: Jennifer Smith | 503-602-1128 | Jennifer.R.Smith@state.or.us .
  2. OHA-MAP will review for qualifying events, and request information on the events and associated costs.
  3. OHA-MAP will work with the clinic to agree upon qualifying events, cost changes and a new rate.

Oregon Medicaid and Coordinated Care Organizations (CCOs)

All clinics, including RHCs, will need to contract with their CCO in order to receive Medicaid reimbursement and wrap-around payments for patients enrolled in CCO insurance plans. Contact the appropriate CCO about providing services for CCO patients.

CCO reimbursement rates cannot be less than your calculated RHC encounter rate; however, full reimbursement may require participating in the “Wrap-around” payments through OHA. Please see the RHC Coding and Billing Resources section of the ORH website for further details. Please contact OHA MAP to assure you are receiving your full reimbursement for OHP encounters: Jennifer Smith | 503-602-1128 | Jennifer.R.Smith@state.or.us .

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

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. RHC Basics and Billing 1010 : Sharon Shover, Senior Manager, Blue & Co, LLC
    2. Basic RHC Billing v. 2020:  Charles James, Jr. North American HMS

Medicaid/Oregon Health Plan (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 8/31/2015: 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 FQHC and RHC Administrative Rulebook 3/20/2020
    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 | eric.larson@state.or.us | 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.

Rural Health Clinics (RHCs) must complete a Medicare Cost Report annually. It is due five months from the date of the end of the RHC’s fiscal year.

The Medicare Cost Report

  1. Determines future reimbursement rates including reimbursement for Influenza and Pneumococcal vaccines given to Medicare patients;
  2. Determines allowable Medicare bad-debt write-off;
  3. Reconciles the RHC’s interim rate payment to the RHC’s actual cost per visit.

The Medicare Fiscal Intermediary may withhold payments for an unfiled Medicare cost report.

The Cost Report forms and process are slightly different for Independent vs. Provider-based RHCs:

  • Independent RHCs: Cost Report form and instructions (CMS-222-92)
  • Provider-based RHCs: Cost Report form and instructions (CMS-2552-10 – M schedules)

Wipfli LLP provides Medicare cost reporting services for both independent and provider-based RHCs.

Contact

Rondyann Gerst | gerst@ohsu.edu | 503-312-3907