Federally Qualified Health Centers (FQHCs) must submit TotalCare claims that comply with Medicare institutional billing requirements. TotalCare is the Alliance’s Dual-Eligible Special Needs Plan (D-SNP) for members who are eligible for both Medicare and Medi-Cal. Claims submitted on incorrect claim forms or with an invalid Type of Bill (TOB) may be denied or delayed.
Billing Requirements – reference
| Exigência | FQHC |
| Required Claim Form | UB-04 (CMS-1450) or 8371 |
| Professional Claim Forms | CMS-1500 / 837P Not Allowed |
| Required Type of Bill (TOB) | 77X |
| TOB Examples | 771 (Admit–Discharge) 772 (Interim–First) 773 (Interim–Continuing) 774 (Interim–Last) 779 (Final) |
| Revenue Codes | 0521, 0522, 0524 (as applicable) |
| HCPCS Codes | FQHC encounter codes per Medicare |
Resources and references
- Medicare Claims Processing Manual (MCPM), Pub. 100-04, Chapter 9 – Federally Qualified Health Centers (FQHCs)
- Section 40 & 40.2:
Requires FQHC claims to be submitted on the UB-04 (CMS-1450) or 837I institutional format. - Section 40.2.1:
Defines required Type of Bill 77X for FQHCs. - Sections 50 & 60:
Outlines encounter definitions, revenue codes, and claim submission requirements.
Questões?
For more information, please call Claims Customer Service at 831-430-5503, Monday–Friday, 8:30 a.m. to 4:30 p.m. and select option 3.
