FQHC Reimbursement Billing Guidelines

There are three different pathways for health centers to follow when billing Ambetter. Billing methods and reimbursement will depend on the provider contract and language.

1. Payor-Specific Contract Language
   • Can bill and receive reimbursement only on a CMS 1500 claim form for all Marketplace covered services
2. Encounter/PPS Contract Language
   • Should bill the appropriate encounter code on UB-04 (CMS 1450)
   • Should bill all other Medicare Covered services (since this is for providers seeking Medicare reimbursement methodology) on a CMS 1500
3. Contract is silent on specific reimbursement terms-Default Billing Method
   • If your contract does not include specific billing language:
     1. Bill the appropriate encounter code on UB-04 (CMS 1450)
     2. Only reimburses adjunct codes covered under Marketplace which should be billed on CMS 1500

Additional Resources:

• CMS FQHC billing guide:
  • https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf
• CMS FQHC FAQ:
  • https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-FAQs.pdf

Providers should ensure billing practices align with the terms of their contract. If you have any additional questions or concerns, please let us know. Providers can request their contract by reaching out to meridianproviderconcierge@mimeridian.com.