21-799m Use Proper Billing for Federally Qualified Health Centers to Receive AB97 Exemption

Date: 11/12/21

This information applies to Federally Qualified Health Centers

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

Required billing for evaluation and management (E&M) services.

As a reminder, the Department of Health Care Services (DHCS) implemented 10% provider payment reductions to most categories of services in Medi-Cal fee-for-service (FFS) following the Assembly Bill 97 (Chapter 3, Statutes of 2011) effective on June 1, 2011. To be exempt from the AB97 reduction, Federally Qualified Health Centers (FQHCs) participating in the CalViva Health Medi-Cal program must bill E&M services as follows:

• Bill on a UB-04 form and use type of bill code 711
• Include HCPCS code with modifier T1015 SE on the first procedure service line (the top line).
• All E&M procedure codes and other services must be billed below the service line for procedure code T1015 (see example below).
  • Note:  Since procedure code T1015 is an all-inclusive clinic visit code, the code will be reimbursed. The additional E&M codes will have no additional reimbursement. Optometry services have a different set of codes and can be reimbursed in addition to T1015. Refer to the DHCS Medi-Cal Provider Training 2021 (PDF)

Example: Managed Care Differential Rate Billing Scenario (This is a sample only. Please adapt to your billing situation.)

John Doe visited a Rural Health Clinic (RHC) for evaluation of his recent chest pain. He is enrolled in a Medi-Cal Managed Care Plan (MCP) and the service is covered under the plan. The RHC bills the MCP for the encounter and submits a claim to Medi-Cal for the managed care differential rate, with revenue code 0521, HCPCS code T1015 with modifier “SE” and an informational line specific to his visit, which in this case is procedure code 99214. This code set is used for FQHC/RHC providers.

Additional information

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.