OAR 410-147-0320: Federally Qualified Health Center Rural Health Clinics Enrollment

(1) This rule outlines the Division of Medical Assistance Programs (Division) enrollment requirements for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) (Refer also to OAR 410-120-1260 and 943-120-0320, Provider Enrollment). (a) For outpatient health programs or facilities operated by an American Indian tribe under the Indian Self-Determination Act (Public Law 93-638), providers should refer to the program rules for American Indian/Alaska Native (AI/AN) Services, OAR chapter 410, division 146, for enrollment details; (b) An FQHC or RHC that operates a retail pharmacy; provides durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); or provides targeted case management (TCM) services, must enroll separately as a pharmacy, DMEPOS and/or TCM provider. For specific information, refer to OAR chapter 410, division 121, Pharmaceutical; OAR chapter 410, division 122, DMEPOS; and OAR chapter 410, division 138, TCM. (c) A county Community Mental Health Program (CMHP) furnishing extended care services under contract with the Oregon Health Authority (Authority) Addictions and Mental Health Division (AMH) should refer to AMH for licensure and reimbursement requirements. (2) To enroll with the Division as an FQHC, a health center must comply with one of the following: (a) Receive Public Health Service (PHS) grant funds under the authority of Section 330; (b) Have received FQHC Look-Alike designation from the Centers for Medicare and Medicaid Services (CMS), based on the recommendation of the Health Resources and Services Administration (HRSA)/Bureau of Primary Health Care (BPHC); or (c) Be an Urban Indian Health Program (UIHP) clinic (under Title V of the Indian Health Care Improvement Act, Public Law 94-437). In the Omnibus Reconciliation Act (OBRA) of 1993, Title V programs were added to the list of specific programs automatically eligible for FQHC designation. (3) Eligible FQHCs who want to enroll with the Division as an FQHC, and receive reimbursement under the Prospective Payment System (PPS) encounter rate methodology, must submit the following information: (a) Completed Authority provider enrollment forms with attachments as required in OAR 943-120-0300 through 943-120-0320; (b) National Provider Identifier (NPI) number and associated taxonomy code(s) obtained for the FQHC with the provider enrollment form (refer to OAR 943-120-0320); (c) Completed Cost Statement(s) (DMAP 3027): (A) One each for medical, dental and mental health (including addiction, alcohol and chemical dependency) (see also OAR 410-147-0360); (B) One for each FQHC-designated site, unless specifically exempted in writing by the Division to file a consolidated cost report (see also OAR 410-147-0340 Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)/provider numbers); (d) Completed copy of the grant proposal submitted to HRSA/BPHC detailing the clinic’s service and geographic scope; (e) Copy of the HRSA Notice of Grant Award Authorization for Public Health Services Funds under Section 330, or a copy of the letter from CMS designating the facility as a “Look Alike” FQHC; (f) A copy of the clinic’s trial balance (see OAR 410-147-0500, Total Encounters for Cost Reports); (g) Audited financial statements (refer to OAR 410-120-1380 Compliance with Federal and State Statutes, and Office of Management and Budget Circular A-133 entitled “Audits of States, Local Governments and Non-Profit Organizations”); (h) Depreciation schedules; (i) Overhead cost allocation schedule; (j) A copy of the clinic’s AMH certification for a program of mental health services if someone other than a licensed psychiatrist, licensed clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, licensed professional counselor or licensed marriage and family therapist is providing mental health services; (k) A copy of the clinic’s AMH letter or licensure of approval if providing Addiction, Alcohol and Chemical Dependency services; (l) A list of all Prepaid Health Plan (PHP) contracts; (m) A list including names and NPI numbers of individual practitioners enrolled with the Division and contracted with or employed by the FQHC; and (n) A list including business names, addresses and facility NPI numbers for all Division-enrolled clinics affiliated or owned by the FQHC including any clinics that do not have FQHC status. (4) For enrollment with the Division as an RHC, a clinic must: (a) Be designated by CMS as an RHC. (b) Maintain Medicare certification and be in compliance with all Medicare requirements for certification. (5) Eligible RHCs who want to enroll with the Division as an RHC, and be eligible for payment under the Prospective Payment System (PPS) encounter rate methodology, must submit the following information: (a) Completed the Authority provider enrollment forms with attachments as required in OAR 943-0120-0300 through 943-120-0320; (b) National Provider Identifier (NPI) number and any associated taxonomy codes obtained for the RHC with the provider enrollment form (refer to OAR 943-120-0320); (c) Copy of Medicare’s letter certifying the clinic as an RHC; (d) Medicare Cost Report for RHC or completed Cost Statement(s) (DMAP 3027) (see OAR 410-147-0360). Complete a cost statement for each RHC-designated site, unless specifically exempted in writing by the Division to file a consolidated cost report (see OAR 410-147-0340): (A) The Division will accept an uncertified Medicare Cost Report; (B) If the clinic’s Medicare Cost Report, provided to the Division, does not include all covered Medicaid costs provided by the clinic, the clinic must submit additional cost information. The Division will include these costs when determining the PPS encounter rate; (C) An RHC can submit the Cost Statement (DMAP 3027) as a substitute to the Medicare Cost Report. (e) A copy of the clinic’s trial balance (see OAR 410-147-0500, Total Encounters for Cost Reports only if completing Cost Statement DMAP 3027); (f) Audited financial statements (refer to OAR 410-120-1380 Compliance with Federal and State Statutes, and Office of Management and Budget Circular A-133 entitled “Audits of States, Local Governments and Non-Profit Organizations” if completing Cost Statement DMAP 3027); (g) Depreciation schedules (only if completing Cost Statement DMAP 3027); (h) Overhead cost allocation schedules (only if completing Cost Statement DMAP 3027); (i) A copy of the clinic’s AMH certification for a program of mental health services if someone other than a licensed psychiatrist, licensed clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, licensed professional counselor or licensed marriage and family therapist is providing mental health services; (j) A copy of the clinic’s AMH letter or licensure of approval if providing Addiction, Alcohol and Chemical Dependency services; (k) A list of all Prepaid Health Plan (PHP) contracts; (l) A list including names and NPI numbers of individual practitioners enrolled with the Division and contracted with or employed by the RHC; and (m) A list including business names, addresses and facility NPI numbers for all Division-enrolled clinics affiliated or owned by the RHC including any clinics that do not have RHC status. (6) The FQHC/RHC Program Manager, upon receipt of the required items as listed in section (3) of this rule for FQHCs and Section (5) of this rule for RHCs, will review all documents for compliance with program rules, completeness and accuracy. (7) The Division prohibits an established, enrolled FQHC or RHC that adds or opens a new clinic site from submitting claims for services rendered at the new site under their FQHC or RHC Division enrollment, and according to the PPS encounter rate, prior to the Division’s acknowledgment. An FQHC or RHC is required to immediately submit to the attention of the FQHC/RHC Program Manager, Division: (a) For FQHCs only, a copy of the recent HRSA Notice of Grant Award including the new site under the main FQHC’s scope; (b) For RHCs only, a copy of Medicare’s letter certifying the new clinic as an RHC; (c) A recent list of all PHP contracts; and (d) A recent list of names and NPI numbers for all individual practitioners enrolled with the Division and contracted with or employed by the new FQHC or RHC site. (8) If an established and enrolled RHC or FQHC changes ownership, the new owner must submit: (a) Cost Statement (DMAP 3027) or Medicare Cost Report within 30 days from the date of change of ownership to have a new PPS encounter rate calculated; or in writing, a letter advising adoption of the PPS encounter rate calculated under the former ownership (see OAR 410-147-0360); (b) Notice of a change in tax identification number; (c) A recent list of all PHP contracts; (d) A recent list of names and NPI numbers for all individual practitioners enrolled with the Division and contracted with or employed by the FQHC or RHC; and (e) A recent list including business names, addresses, NPI numbers and associated taxonomy codes for all Division-enrolled clinics affiliated or owned by the FQHC or RHC including any clinics that do not have FQHC or RHC status. (9) FQHCs that are involved with a sub-recipient must provide documentation. Sub-recipient contracts with an FQHC must enroll as an FQHC and submit the same required documentation as outlined under the enrollment sections of this rule.