New Editing Established for Federally Qualified Health Center and Rural Health Clinics

Published 06/28/2021

For claims processed on and after July 1, 2021, editing is being established for claims submitted by a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) for Medicare Part B Jurisdiction J.  

If you are designated by Medicare as a FQHC or a RHC and perform services that are outside the scope of the FQHC or RHC, it is the responsibility of the clinic to ensure that the service is submitted to the correct Medicare Administrative Contractor, for either Part A or Part B. 

Only Independent FQHCs or RHCs should be submitting services to Medicare Part B for non-clinic services. Please follow CMS Internet Only Manual instructions found in the Benefit Policy Manual, 100-2, Chapter 13 (PDF, 470 KB) and the Claims Processing Manual, 100-4, Chapter 9 (PDF, 312 KB) to ensure proper billing.

Monitoring will continue to ensure that services are not paid by both A and B. Clinic services submitted to Part B that should be included in the All Inclusive Rate (AIR) or those that are considered a FQHC or RHC benefit will be denied as they should be submitted to Part A. Claims will be denied with the following CARC and RARC messages below:

CARC 109 — Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

RARC N418 — Misrouted claim. See the payer’s claim submission instructions.   

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