Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Services

FQHCs and RHCs provide covered services to PrimeWest Health members in a manner similar to other physician clinics. However, Federal mandates and guidelines apply specifically to FQHCs/RHCs. See Claims & Payment.

It is the provider’s responsibility to submit RHC rates to PrimeWest Health and update PrimeWest Health with any changes to the rates prior to the submission of claims for that rate period. Once PrimeWest Health receives the updated rates, providers should allow up to 15 business days for programming of the rates to be completed. PrimeWest Health does not reprocess claims received prior to the date the change is made in its system.

Providers should email or fax all RHC rate updates and changes to PrimeWest Health at the following:

Email: claims@primewest.org 
Fax: 1-320-762-1805

PrimeWest Health requires all RHC providers to fax or email RHC rates for claims processing on an annual basis. PrimeWest Health follows up with contracted RHC providers on a quarterly basis to verify their current RHC rate.

PrimeWest Health processes all RHC claims with the current rates on file at PrimeWest Health at the time the claim is received, regardless of participating or non-participating provider status with the PrimeWest Health provider network. If the current rates on file were received more than one year ago, claims will deny. Providers must send updated rates and resubmit the claim to be considered for reimbursement.

Eligible Providers

Providers that meet the definition of an FQHC/RHC must enroll as an FQHC/RHC to receive consideration for payment under the Prospective Payment System (PPS) or Alternative Payment Methodology (APM).

Covered Services for Medical Assistance (Medicaid) Members

PrimeWest Health covers one medical and/or one dental encounter per day for Federally funded Medical Assistance (Medicaid) and MinnesotaCare members with Medical Assistance (Medicaid) benefits. A medical encounter does not prohibit a dental encounter from being incurred on the same day. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the patient suffers illness or injury after the first encounter that requires additional diagnosis or treatment. PrimeWest Health coverage includes the following:

1. Dental services
2. Drugs and biologicals furnished as “incidental to” an FQHC or RHC professional service, only if they cannot be self-administered
3. FQHC or RHC professional services provided to FQHC or RHC patients if covering inpatient hospital visits
4. FQHC or RHC professional services provided to FQHC or RHC patients if surgical services are directly provided by the center or clinic
5. In an area in which a shortage of home health agencies exists, part-time or intermittent nursing care by a RN or LPN to a homebound individual under a written plan of treatment, either established and reviewed by a physician every 60 days or established by an NP or PA and reviewed at least every 60 days by a supervising physician
6. Mental health services provided in compliance with mental health guidelines
7. Obstetrical and perinatal care
8. Pharmaceuticals provided by an FQHC or RHC in compliance with pharmacy guidelines
9. FQHC or RHC professional services and supplies furnished as incident to an FQHC or RHC professional service
10. Services and supplies are incident to an FQHC or RHC professional services and are covered by the encounter rate if they are:
    1. Of a type commonly furnished in physicians’ offices
    2. Of a type commonly rendered either without charge or included in the bill
    3. Furnished as an incidental, although integral, part of a physician’s professional services
    4. Furnished under the direct, personal supervision of a physician
    5. Provided by a member of the clinic's health care staff who is an employee of the clinic
    6. Vaccines (for example, pneumococcal, influenza, and hepatitis B)

In addition, Medical Assistance (Medicaid) coverage of services furnished by an FQHC/RHC includes all other ambulatory services covered under the Minnesota State Plan, which are furnished by the FQHC/RHC. With the exception of dental services, ambulatory services are considered part of the medical encounters and are included in the development of the medical encounter payment rate for both PPS and Minnesota’s Alternative Payment Methodologies (MAPMs).

FQHC/RHC Billing Requirements

Use the following guidelines when billing PrimeWest Health for services provided by an FQHC or RHC:

1. Bill claims for Medical Assistance (Medicaid)-covered services using the 837P (Professional) claim format. Bill claims for Medicare-covered services using the 837I (Institutional) claim format
2. Bill dental claims using the 837D (Dental) claim format and include tooth number, quadrant, or surface as appropriate
3. Use the NPI assigned to the FQHC/RHC location to bill all PrimeWest Health services
4. Use the NPI of the rendering/treating provider
5. Follow all frequency guidelines and request for authorization requirements
6. Enter time units according to the requirements for the services provided
7. Use applicable modifiers
8. For FQHCs using HCPCS codes T1017 and T2023, continue to use applicable code

Effective January 1, 2018, PrimeWest Health no longer accepts claims on the 837P (Professional) claim format for Medicare-covered services.

PrimeWest Health covers one medical and/or one dental encounter per day, for Federally funded Medical Assistance (Medicaid) and MinnesotaCare members with Medical Assistance (Medicaid) benefits.

Note: the previous claim format changes do not apply to Medicare crossover claims or Global Procedure Service Date Reporting.

FQHC and RHC Managed Care Organization (MCO) Carve-out

The following are carve-out process exclusions:

1. Medicare claims follow standard billing practices. PrimeWest Health handles final resolution, and does not forward claims to DHS.
2. Claims in which a third party insurer (TPL) paid the claim in full
3. Medical home (health care home) claims procedure codes S0280 and S0281. PrimeWest Health will continue to pay these claims directly to the provider.
4. PrimeWest Health pays directly for MinnesotaCare member claims

Effective for service dates beginning July 1, 2019, FQHCs must submit claims for PrimeWest Health members directly to MHCP for payment. RHCs must continue to follow the MCO carve-out process.

FQHC full MCO carve-out effective July 1, 2019

All MHCP claims submission rules apply to the full MCO carve-out process, including prior authorizations, benefit limits, copays, and interpreter services.

The following are carve-out process exclusions:

1. Medicare claims follow standard billing practice. PrimeWest Health handles final resolution.
2. Medical home (health care home) claims procedure codes S0280 and S0281. PrimeWest Health will continue to pay these claims directly to the provider.
3. MinnesotaCare claims. PrimeWest Health will continue to pay these claims directly to the provider.

FQHC and RHC Medicare crossover claims

MHCP will deny FQHC and RHC Medicare-denied (for non-coverage) 837I crossover claims with remark code N34. FQHCs and RHCs must resubmit 837I Medicare-denied crossover claims using the 837P format.

Additional details from MHCP regarding this carve-out can be found on the Minnesota Department of Human Services (DHS) Federally Qualified Health Center and Rural Health Clinics web page. 

Pharmacy Copays

Pharmacy copay information will be provided to the pharmacist, and tracking of the monthly copay obligation will occur. As pharmacy services are part of the medical encounter, no separate pharmacy payment is made. For Medical Assistance (Medicaid) payments to reflect the applicable pharmacy copays, recognition of copay amounts that apply to FQHC/RHC services will occur during the payment cycle in which the pharmacy service occurred.

Collect copays at the time of the visit or bill the member, according to office policy.

Dentures/Partials

1. For appointments prior to the delivery of the denture/partial, utilize code D5899 and enter “Encounter in preparation for denture/partial” as the description.
2. Bill the appropriate code for the denture/partial when the appliance is delivered to the member.
3. For all adjustment appointments after the delivery of the appliance, utilize code D5899 and enter “Encounter for denture adjustment” as the description.

Billing

Bill services provided to PrimeWest Health members electronically using the 837P format for all services except Medicare covered services. For dual eligible program (PrimeWest Senior Health Complete [HMO SNP] and Prime Health Complete [HMO SNP]) services, refer to your PrimeWest Health Participation Agreement for the payment terms. If you are reimbursed based on the CMS or DHS fee schedule, itemize all charges and submit electronically using the 837P format.

For coordination of benefits (COB) crossover claims where PrimeWest Health is secondary, you may submit the claims in the same format used to bill the primary payer.

Follow any frequency guidelines or request for authorization requirements.

Review the C&TC Screening Service Billing/Coding section of Children’s Services, for C&TC encounter billing instructions.

PW_11-19_533
Updated_12/11/2025