Resources & Technical Assistance
These resources should be considered general and preliminary only. Final determination of rural status will be made by the State of Oregon. Please contact Janice McDowell, RN, firstname.lastname@example.org, (971) 673-3269, at Health Care Regulation and Quality Improvement (HCRQI) for final determination.
- Does the clinic qualify as a rural site?
- The clinic is not in a Census Urbanized Area:
- The clinic is in a current Health Professions Shortage Area (HPSA) or a Medically Underserved Area (MUA) issued or renewed within the previous four years.
HPSA: The age of the designation is calculated as the last day of the year 4 years from the date of the original designation, or the date the area was last designated. For example, a clinic that is located in an area that was most recently designated or updated on June 1, 2010, would be considered as meeting this location requirement through December 31, 2014. In Oregon, HPSA scores are updated every three years by the Oregon Health Authority’s Primary Care Office. To ensure your area’s HPSA score has not expired, contact: PCO.Oregon@state.or.us | (503) 373-1779.
MUA: MUAs do not expire however if you are using an MUA for RHC purposes, and do not have a HPSA. The MUA designation must have been issued within the past four years.
- Is there a financial benefit to RHC status for the clinic?
RHCs (and FQHCs) receive special Medicare and Medicaid reimbursement rates for the care they provide. The RHC rate benefit can vary from clinic to clinic depending on the type of services that the clinic provides and the payer mix of the patient population.
- As an introductory resource, a basic Medicare-focused financial analysis worksheet is available in Starting a Rural Health Clinic, Appendix F.
- ORH can assist you with a more detailed Medicare and Medicaid financial impact analysis of your current Fee-for-Service rates vs. current RHC rates. Please contact: Stacie Rothwell, Program Manager | email@example.com | 503-494-4450, or Rebecca Dobert, Program Manager | firstname.lastname@example.org | 971-271-0481.
- Wipfli LLP can provide various services to clinics considering RHC status.
- Does the clinic meet RHC personnel requirements?
More than 50% of the clinic’s services must be Primary Care: Family Care, Internal Medicine, OB/GYN, and Pediatrics. An RHC must:
- Employ a Nurse Practitioner (NP) or Physician Assistant (PA)
RHCs may contract with NPs, PAs, Certified Nurse Midwives (CNM), Clinical Psychologists (CP), and Clinical Social Workers (CSW) when at least one NP or PA is employed by the RHC.
- Have an NP, PA, or CNM (employee + contract) working at the clinic at least 50 percent of the time the clinic operates.
- Employ a Nurse Practitioner (NP) or Physician Assistant (PA)
- Starting a Rural Health Clinic—A How-To Manual
- Medicare Benefit Policy Manual: Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services
- US Department of Health and Human Services Rural Health Information Hub
- National Association of Rural Health Clinics
- National Rural Health Association
- Centers for Medicare & Medicaid Services
- Oregon Health Authority, Medical Assistant Program
- Oregon Health Authority, Office of Equity: Oregon Health Care Interpreter Registry
The Health Care Regulation and Quality Improvement (HCRQI) Section of the Oregon Health Authority (OHA) has an agreement with the Center for Medicare and Medicaid Services (CMS), to assist in determining whether health care facilities meet, and continue to meet, required conditions of participation. Questions about the application and survey may be directed to Janice McDowell, RN | email@example.com | (971) 673-3269.
- Complete and return the following forms to HCRQI Program | FAX: (971) 673-0556
- Health Insurance Benefit Agreement: HCFA 1561 A (two signed originals required)
- Request to Establish Eligibility: HCFA 29
- The following is also required for Provider-based RHCs:
New applicants for Medicare funding and current providers undergoing a change of ownership are responsible for submitting an Assurance of Compliance (HHS-690) attesting that they will comply with all applicable civil rights laws enforceable by OCR (Title VI, Section 504, Title IX, the Age Discrimination Act, and Section 1557).
As of September 1, 2016, OCR is accepting the HHS-690 only via the online Assurance of Compliance portal. Upon submission of the HHS-690, the providers will receive a notification that the document has been successfully submitted. Clinics should print out and include the confirmation as part of their application packet. The providers are responsible for notifying CMS and/or the state survey agency.
- Complete the Medicare Enrollment Application: This must be completed and approved prior to scheduling a survey. The initial enrollment fee is currently $569 – see PECOS online payment.
Once the HCRQI program office has received approval of the application CMS-855A from Noridian, a written request should be submitted to the HCRQI Program for a survey of the clinic. All forms must be complete, signed and submitted prior to scheduling the survey. Please note: this will be an unannounced onsite survey. It is very important to carefully and adequately prepare for the RHC accreditation inspection. Failure of this inspection can substantially delay certification of the clinic for RHC status. In addition, if the clinic should fail the initial HCRQI inspection, it will be required to hire a private contractor for a follow-up certification inspection. To assure that a clinic meets certification inspection criteria, they will need to:
- Develop an RHC Policy and Procedure Manual (a sample manual is available in Appendix D of the Starting a Rural Health Clinic – A How-To Manual, or Provider- based clinics may use this template.
- Ensure clinic lab services are in place and licensed – CLIA Application
Contact: The Oregon Laboratory Compliance Section (503-693-4126).
The clinic must have the ability to perform the following lab procedures onsite:
- Chemical examination of urine by stick or tablet method or both
- Hemoglobin or hematocrit
- Blood sugar
- Examination of stool specimens for occult blood
- Pregnancy tests
- Primary culturing for transmittal to a certified laboratory
Ensure that the clinic meets all conditions of certification that the HCRQI survey staff are directed to assess:
- Review CMS rules to surveyors
- Review the survey preparation checklist from HCRQI Program office will assist you in preparing for the survey.
- Conduct practice inspections:
- ORH can arrange to perform a mock inspection of a clinic to identify areas of improvement necessary prior to the official HCRQI Program survey. Please contact Stacie Rothwell, Program Manager | firstname.lastname@example.org | 971-235-3978, or Rebecca Dobert, Program Manager | email@example.com | 971-271-0481.
- If a clinic plans to conduct practice inspections independently, a detailed survey preparation checklist, created by ORH and Wipfli, is available. The checklist details the specific items of focus needed to meet Federal RHC certification.
Alternative Vendor Certification options: potentially faster alternative accreditation options are available for clinics that are willing/able to pay. Two companies, American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAASF) and The Compliance Team, are authorized by the CMS to offer certification services. Additional details available here.
For information on Medicaid in Oregon, refer to the Oregon Health Authority Division of Medical Assistance Programs Oregon Administrative Rules.
- Complete the following RHC enrollment forms: DMAP 3104, OHA 3972, OHA 3974, and OHA 3975. Available at: OHP Provider Enrollment.
- The clinic’s RHC Certification Letter, received from Oregon’s CMS Medicare Administrative Contractor Noridian.
- An IRS letter confirming tax ID and status. This is a general requirement for all clinics to operate as a business, regardless of RHC status.
- Clinical Laboratory Improvement Amendments (CLIA) Certificate from the Oregon Health Authority’s (OHA) Office of Clinical Laboratory Regulation.
- Medicare Cost Report. This is the Cost Report completed for Medicare payment and rate calculation. For important details regarding the Cost Report and Oregon Medicaid, pay close attention to OAR 410-147-0480 Cost Statement Instructions and OAR 410-147-0500 Total Encounters for Cost Reports.
- Submit all of the above to the OHA Medical Assistance Program (MAP): Jamal Furqan | 503-945-6683 | firstname.lastname@example.org.
RHC Rate Calculation and Increases
Initial RHC Rate Determination
The Medicare Cost Report informs the RHC rate calculation, which will set the clinic’s Medicaid RHC encounter rate. This rate is adjusted annually based on the Medicare Economic Index (MEI). The RHC will be enrolled with Oregon Medicaid on the date the PPS encounter rate is determined.
Oregon Medicaid Change in Scope
A change in the scope of RHC services may occur if the RHC has added, dropped or expanded any service that meets the definition of an RHC service. Full details at OAR 410-147-0362. If there is a change in scope which significantly changes the cost of services, a change of scope may be requested in order to qualify for a readjusted rate.
- Submit a narrative outlining the proposed qualifying events for a change in scope to the OHA-MAP: Jamal Furqan | 503-945-6683 | email@example.com.
- OHA-MAP will review for qualifying events, and request information on the events and associated costs.
- OHA-MAP will work with the clinic to agree upon qualifying events, cost changes and a new rate.
Oregon Medicaid and Coordinated Care Organizations (CCOs)
All clinics, including RHCs, will need to contract with their CCO in order to receive Medicaid reimbursement and wrap-around payments for patients enrolled in CCO insurance plans. Contact the appropriate CCO about providing services for CCO patients.
CCO reimbursement rates cannot be less than your calculated RHC encounter rate; however, full reimbursement may require participating in the “Wrap-around” payments through OHA. Please see the RHC Coding and Billing Resources section of the ORH website for further details. Please contact OHA MAP to assure you are receiving your full reimbursement for OHP encounters: Jamal Furqan | 503-945-6683 | firstname.lastname@example.org.
It is important to understand that there are differences in the reimbursement rates for Independent RHCs and Provider-based RHCs.
- Medicare Billing and Reimbursement
- Noridian Healthcare Solutions
Noridian acts as the Medicare Administrative Contractor (MAC) for Oregon and other Western states. They publish an RHC Medicare billing guide for Medicare related billing questions.
- CMS Rural Health Clinic Center
- Medicare Claims Processing Manual, Chapter 18 – Preventive and Screening Services
- Medicare RHC Benefit Policy Manual
- Medicare RHC Claims Processing Manual
- Medicare Billing guidance for Preventative Services
- Provider Wraparound Data Template | Note: Both the “Cover Page” and “Raw Data” tabs must be completed for submissions.
- Helpful Presentations
- Noridian Healthcare Solutions
- Medicaid/Oregon Health Plan (OHP) Billing and Reimbursement
- Billing Basics: Oregon Health Authority (OHA) presentation on billing information for all providers who serve Medicaid clients.
- FQHC-RHC Provider Guide, 9-1-2012: Two page document with links to resources at the Oregon Health Authority’s Medical Assistance Programs (OHA MAP).
- Oregon Medicaid Professional Billing Instructions: includes RHC billing submission process to OHA MAP.
- For reference: OHA MAP FQHC & RHC Administrative Rulebook
- If in doubt of which claim format to use, contact OHA MAP Provider Services at 800-336-6016 for assistance.
- OHA MAP Training
OHA MAP holds a Program Meeting, every two months, specifically for RHCs, FQHCs and Tribal Health Clinics, to provide information and updates, and as an opportunity for questions related to OHP. Information is also sent to registered participants. To be added to the announcement list, please contact Jamal Furqan | 503-945-6683 | email@example.com.
OHA MAP Trainer: Jennifer Smith, firstname.lastname@example.org, 503-602-1128.
- Oregon Medicaid Prepaid Health Plan Supplemental Payments (“Wraparound”)
Federal rule requires OHA MAP to make supplemental payments (“wraparound payments”) to RHCs that contract with Prepaid Health Plans (PHP). The wraparound payment represents the difference, if any, between the payment received by the RHC from the PHP for treating the enrolled patient and the payment to which the RHC would be entitled if they had billed MAP directly for these encounters according to the RHC’s Prospective Payment System (PPS) encounter rate (OAR 410-147-0460). The OHA MAP Policy Analyst will coordinate this process with each RHC upon enrollment with Oregon Medicaid. Contact: Eric Larson, Fiscal Auditor, email@example.com, (503)945-5991.
- Oregon Medicaid and Change-in-Scope: A change in the scope of RHC services may occur if the RHC has added, dropped or expanded any service since initial certification. Please see Enrolling with Oregon Medicaid for further details on Oregon Medicaid Change in Scope.
Rural Health Clinics (RHCs) must complete a Medicare Cost Report annually. It is due five months from the date of the end of the RHC’s fiscal year.
The Medicare Cost Report
- Determines future reimbursement rates including reimbursement for Influenza and Pneumococcal vaccines given to Medicare patients;
- Determines allowable Medicare bad-debt write-off;
- Reconciles the RHC’s interim rate payment to the RHC’s actual cost per visit.
The Medicare Fiscal Intermediary may withhold payments for an unfiled Medicare cost report.
The Cost Report forms and process are slightly different for Independent vs. Provider-based RHCs:
- Independent RHCs: Cost Report form and instructions (CMS-222-92)
- Provider-based RHCs: Cost Report form and instructions (CMS-2552-10 – M schedules)