FQHC/RHC/IHS-MOA Code Conversion Denials
November 15, 2017
The Federally Qualified Health Centers (FQHC) Rural Health Clinics (RHC) and Indian Health Services-Memorandum of Agreement (IHS-MOA) code conversion is effective for dates of service on or after October 1, 2017.
Claims have been monitored to identify the most common denials due to providers billing incorrectly after the transition date. The table below cites the most frequent Remittance Advice Details (RAD) codes and includes tips intended to help providers minimize future claim denials. Additionally, providers should correct and resubmit the denied claims in accordance with timeliness requirements.
||Health Care Plan enrollee, capitated service not billable to Medi-Cal.
||Medi-Cal recipients enrolled in contracting Managed Care Plans (MCP) must receive Medi-Cal benefits from plan providers and not from providers who bill through the fee-for-service program. Providers must contact the individual plan for billing instructions.
||Provider billing error. Claim line is invalid. Verify line charge, procedure code and other line information.
||Informational lines that are completed incorrectly may result in a denial. In order to correctly submit informational lines please follow the informational line guidelines below.
||Valid rate not on file for claim period of service. Contact the Telephone Service Center (TSC).
||Claims submitted with dates of service before October 1, 2017, will use local codes. Claims submitted with dates of service on or after October 1, 2017, must use the HIPAA-compliant billing code sets found on the crosswalks.
||The quantity entered on the claim form is missing/invalid.
||In order for an informational line to be valid the payable line must represent the quantity of the global visit, while the informational line must be left blank on paper claims; blank(s) (space[s]) or zero(s) are acceptable in the Total Charges field for Computer Media Claims (CMC).
||The service code combination is not valid for billing provider.
||Verify the crosswalk requirements for the HIPAA-compliant billing code set being used. Follow the HIPAA-compliant billing code set and informational line guidelines below.
HIPAA-Compliant Billing Code Set Guidelines
A HIPAA-compliant billing code set is a unique combination of service codes used to identify the face-to-face (one-on-one) encounter between the recipient and the provider, during which time one or more services are furnished. The code set may consist of one of the following:
- Revenue code;
- Revenue code and CPT-4 Level I or HCPCS Level II code; or
- Revenue code and CPT-4 Level I or HCPCS Level II code with a modifier.
Informational Line Guidelines
An informational line is an associated line item or line items listed immediately following the HIPAA-compliant billing code set used to bill the face-to-face encounter with the recipient. Informational lines contain only the specific CPT-4 Level I or HCPCS Level II code(s) which identifies the actual service(s) provided, and are not separately reimbursed. When submitting informational lines providers should remember:
- The Revenue Code field (Box 42) on the information claim detail line must always be blank on paper claim forms; blanks (spaces) or zeros are accepted in the Revenue Code field for CMC.
- The Service Units field (Box 46) on the information claim detail line must always be zeros.
- The Total Charges field (Box 47) for each information claim detail line must always be zeros on paper claim forms; blanks (spaces) or zeros are accepted in the Total Charges field for CMC.