Federally qualified health center (FQHC)

Quick reference guide

What is a federally qualified health center (FQHC)?

A federally qualified health center (FQHC) is a Medicare-certified community-based organization that provides comprehensive primary and preventive care. The services provided include medical, dental, and mental health/substance use disorder, and are provided to persons of all ages regardless of their ability to pay or health insurance status. FQHCs may be located in rural or urban areas, and must have a core staff of appropriately trained primary care practitioners.

How are rates established?

FQHC payments are based on a prospective payment system (PPS). The Medicare FQHC PPS is a bundled payment that drives efficiency, not cost-based reimbursement, therefore, FQHCs receive a single bundled rate for each qualifying patient visit. Reimbursement for immunizations is included in this bundled rate for the Medicare Advantage population.

FQHC PPS rates are updated annually using a specific market base rate. This national PPS rate is then adjusted based on geographic location. Pennsylvania FQHC providers receive notification of their annual payment increase from the Pennsylvania Department of Human Services. Capital Blue Cross requests PPS rate letters be provided annually to ensure up-to-date rates are reflected for FQHC claims processing. Reimbursement for immunizations is not included in this rate. PPS Rate letters can be submitted to Capital Blue Cross via email.

General billing requirements

FQHC providers are required to bill their full PPS Payment Rate on the first line of the claim along with the applicable code, determined by the member’s benefits.

Claims for Children’s Health Insurance Plan (CHIP) members should be billed using a 1500 claim form, and the PPS rate should be billed with code T1015 on the first line of the claim.

Code T1015 should never be submitted with zero charge amounts. Claims for Medicare Advantage members should be billed using a UB-04 claim form, and the PPS rate should be billing with one of the following G codes:

  • G0466
  • G0467
  • G0468
  • G0469
  • G0470

In addition, CPT codes and associated charges for all services performed during the encounter must be reflected on subsequent lines of the claim.

Need additional information?

Additional information related to The Centers for Medicare and Medicaid Services (CMS) guidelines for FQHC providers can be found via the following links: