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317:30-5-664.3.Federally Qualified Health Center (FQHC) encounters
[Revised 09-01-19]

(a) FQHC encounters that are billed to the Oklahoma Health Care Authority (OHCA) must meet the definition in this Section and are limited to services covered by OHCA.  Only encounters provided by the authorized health care professional on the approved FQHC state plan pages within the scope of their licensure trigger a prospective payment system encounter rate.
(b) An encounter is defined as a face-to-face contact between a health care professional and a member for the provision of defined services through a FQHC within a 24-hour period ending at midnight, as documented in the member's medical record.

(c) An FQHC may bill for one medically necessary encounter per 24 hour period when the appropriate modifier is applied. Medical review will be required for additional visits for children. For information about multiple encounters, refer to Oklahoma Administrative Code (OAC) 317:30-5-664.4. Payment is limited to four (4) visits per member per month for adults.

(d) Services considered reimbursable encounters (including any related medical supplies provided during the course of the encounter) include:

(1) medical;

(2) diagnostic;

(3) dental, medical and behavioral health screenings;

(4) vision;

(5) physical therapy;

(6) occupational therapy;

(7) podiatry;

(8) behavioral health;

(9) speech;

(10) hearing;

(11) medically necessary FQHC encounters with a registered nurse or  licensed practical nurse and related medical supplies (other than drugs and biologicals) furnished on a part-time or intermittent basis to home-bound members (refer to OAC 317:30-5-661.3); and

(12) any other medically necessary health services (i.e. optometry and podiatry) are also reimbursable as permitted within the FQHCs scope of services when medically reasonable and necessary for the diagnosis or treatment of illness or injury, and must meet all applicable coverage requirements.

(e) Services and supplies incident to a physician's professional service are reimbursable within the encounter if the service or supply is:

(1) of a type commonly furnished in physicians' offices;

(2) of a type commonly rendered either without a charge or included in the health clinic's 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; and

(5) in the case of a service, furnished by a member of the clinic's health care staff who is an employee of the clinic.

(f) Only drugs and biologicals which cannot be self-administered are included within the scope of this benefit.


Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.