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FQHC and RHC Billing Guidance

Known Issues Impacting FQHC/RHC Providers

Stay up to date with known issues, resolution, and timelines on our Known Issues Tracker (PDF), updated weekly by Friday morning.

Wrap Payments

Standard Plan wrap payments went live on August 1, 2024 using a new methodology Prospective Payment System - Alternate Payment Methodology (PPS-APM) rate for Core Service, Well Child and Dental visits based on 113% of Medicaid Allowable Costs.

  • Providers will be reimbursed statewide base rates by Standard Plans for Core Services (T1015) and Well Child Visit (99381EP-99385EP; 99391EP-99395EP) covered services.  The base rates are as follows:
    • T1015 for FQHCs:  $117.32
    • T1015 for RHCs: $83.30
    • Well Child for FQHC/RHC: $80.33
  • Simultaneously with the paid T1015 and Well Child base rates, Standard Plans are expected to reimburse FQHC/RHC providers a wrap payment equal to the difference between the provider specific PPS-APM rate and the base rate.
  • The wrap payment amount will be reported on the provider’s ASCx12 835 ERA under the Service Payment Information in the Service Adjustment segment with a Claim Adjustment Reason Code of ‘172’ (Payment is adjusted when performed by a provider of this specialty)
    • The “wrap” amount listed under Monetary/Adjustment Amount shall be negative to show additional funds were remitted to the provider
    • The Provider Paid amount reported on the provider’s remittance shall equal the Base Rate amount for a Core Service Visit or a Well Child Visit plus the “wrap” amount
  • Providers will continue to bill and be reimbursed by the Standard Plans for the following ancillary covered services based on the applicable codes on the FQHC/RHC Medicaid Fee Schedules:
    • Diagnostic Laboratory Services
    • Physician Hospital Services
    • Pharmacy Services
    • Incentive Payments
  • Providers will continue to bill all other ancillary services rendered for covered FQHC/RHC services; however, these ancillary services will be set to reimburse zero based on the NC Medicaid Fee Schedule. The reimbursement for these services has been factored into the grossed-up PPS-APM rate paid on Core Service, Well Child and Dental encounters.

 *Please also reference CMS guidance for CMS code level requirements (i.e. appropriate revenue codes, "G" codes and payment codes.)

Source: NC Medicaid Blog "Updated: Federally Qualified Health Centers and Rural Health Clinics Reimbursement Methodology Changes Approved"

  • Claims for adult members must include T1015 (core service) for medical visits, as outlined in the billing guide and Clinical Policy 1D-4. Claims without T1015 are considered incomplete under the PPS/APM methodology.
  • T1015 is reimbursed from the FQHC PPS/APM fee schedule by NPI. The new FQHC Physician Services fee schedule applies to all other services.
  • Services listed with a $0 rate on this fee schedule are considered “EXVI” (included in PPS/APM rate and not separately reimbursable).
  • All other services are paid according to the new fee schedule — with or without T1015 — depending on their designation.

FQHCs can bill T1015 up to 3 times a day per member with different modifiers. For example:

  • 1 – CPT T1015 - No Modifier per day per member –Well Visit
  • 1 – CPT T1015 - Modifier HI per day per member –Behavioral Health
  • 1 – CPT T1015 - Modifier SC per day per member-Non-Behavioral sick visit
  • Telehealth visits Modifier GT should be added to any claim

*You may also refer to the Health Plan Billing Guide manual section 3.8 Federally Qualified Health Centers and Rural Health Clinics (RHCs) as well as Medicaid clinical coverage policy 1D-4.

  • FQHCs should use POS 50.
  • RHCs should use POS 72, EXCEPT lab services with a POS 11.

  • The Group NPI should be placed in the WEDI 837P within the 2010AA
    loop (NM108=XX NM109 = NPI) or within Box 33a of the CMS-1500version 02/12.
  • This must be the Group NPI registered with NCTracks as your official FQHC or RHC provider NPI.

  • Always include the actual location where the care was provided on your claim. This address must match what is listed with NCTracks for your practice.
  • If the Physical Address where the services were rendered is different from the Bill-To Address on 2010AA or Box 33, then you must include the Service Address in WEDI 837P within the 2310C Loop or within Box 32 of the CMS-1500 version 02/12.
  • If the Physical Address where the services were rendered is the same as the Bill-To Address on 2010AA or Box 33, then there is no need to complete WEDI 837P 2310C Loop or Box 32 of the CMS-1500 version 02/12.  

If the person providing the service is not the same as the billing provider, you must include the Rendering Providers full name (first and last name) and NPI on the claim. 

  • For electronic claims (837): When providers perform services for a subscriber/patient, the  service will need to be reported in the Rendering Provider Loop (2310B or 2420A). You should only use 2420A when it is different than Loop 2310B/NM1*82. 
  • For the CMS-1500 version 02/12, the Rendering Provider should be placed in Box 31 and the NPI should be placed in Box 24 (unshaded) for each service line billed.

Yes, Include the taxonomy code. 

  • For professional claims (ASC X12 837-P)
    • the billing provider taxonomy should go in EDI loop 2000A
    • the rendering provider taxonomy (when applicable) should go in EDI loop 2310B. 
  • On institutional claims (ASC X12 837-I):
    • the billing provider taxonomy should be included in EDI loop 2000A.
    • attending provider taxonomy, when applicable, should be included in EDI loop 2310A. 
  • Please also view our Provider Taxonomy Guide (PDF)

  • Per the NC Medicaid core services guidelines, FQHC and RHC core services are billed under the FQHC and RHC provider number using the HCPCS code T1015.
  • FQHC/RHCs must also include all CPT codes for services provided during the encounter priced at zero dollars on subsequent lines.
  • NOTE* FQHC and RHC's can bill T1015 up to 3 times a day per member with different modifiers: 
    • 1 – CPT  T1015: No Modifier per day per member -Well Visit
    • 1 – CPT  T1015: Modifier HI per day per member-Behavioral Health 
    • 1 – CPT  T1015: Modifier SC per day per member-Non-Behavioral sick visit
    • Telehealth visits Modifier GT should be added to any claim.

  • NCTracks is the “system of record” for provider enrollment data that is shared with health plans.
  • If provider information is not current, then the data that flows forward to the health plans and the enrollment broker will not be accurate and will cause:
    • Payment delays
    • Incorrect provider directory listings
    • Contracting and credentialing issues

Electronic submission is the preferred method for claim submission. CCH also processes physical health claims for Partners and Trillium Tailored Plan physical health. Here are the electronic submission methods for each line of business:

Sign up for free Electronic Fund Transfer (for fast payments and remittance advice).   

Page Last Updated: 06/27/2025