Will FQHC, RHC and IHS billing codes that are not specific to the OBE policy, but may include non-covered optional benefits services, require medical justification?
Yes. If the services rendered for that visit include optional benefit services that are no longer covered. FQHC/RHC/IHS billing code “01 – Medi-Cal Per Visit Code,” IHS service codes “23 – Medi-Cal Other Health” and “24 – Ambulatory State Plan Visit” require medical justification as a remark or an attachment to the claim if the visit included any of the non-covered optional benefits services, except when rendered by a physician, an EPSDT-eligible beneficiary, or a Medi-Cal/Medicare crossover claim. Additionally, appropriate documentation must be retained in the beneficiary’s medical record. Clinics should only use these “Visit Codes” for billing excluded optional benefits for beneficiaries who are exempt. Example: if visit code 01 is used for podiatry visit, a medical justification as either a remark on the claim or as an attachment is required. Please review the Optional Benefits Exclusion Policy: Additional Billing Information for FQHCs, RHCs and IHS article for detailed information
Related Questions
- Will FQHC, RHC and IHS billing codes that are not specific to the OBE policy, but may include non-covered optional benefits services, require medical justification?
- Are FQHC, RHC and Indian Health Services (IHS) claims required to have medical justification as either a remark on the claim or as an attachment to the claim?
- What is EFTSs policy on Back Billing?
