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Billing Tips

10 Important Billing Tips for FQHC and RHC Providers

1. Always bill the correct place of service.

  • For FQHCs, place of service is 50.
  • For RHCs, place of service is 72, however, you can bill lab services with a place of service 11.

2. Always include the correct FHQC/RHC Group Bill-To NPI and place it in the WEDI 837P within the 2010AA loop (NM108=XX NM109 = NPI) or within Box 33a of the CMS-1500 version 02/12.

  • This must be the Group NPI registered with the South Carolina DHHS as your FQHC or RHC provider NPI. 

3. Always include the physical address where the services were rendered on your claim. This should be the address on file with the State Medicaid Program.

  • If the Physical Address where the services were rendered is different from the Bill-To Address on 2010AA or Box 33, then you must include the Service Address in WEDI 837P within the 2310C Loop or within Box 32 of the CMS-1500 version 02/12.
  • If the Physical Address where the services were rendered is the same as the Bill-To Address on 2010AA or Box 33, then there is no need to complete WEDI 837P 2310C Loop or Box 32 of the CMS-1500 version 02/12. 

4. If the Rendering provider performing the services is not the same as the Bill-To Provider, you must include the correct Individual’s Name (First and Last Name) and their NPI on the claim.

  • For Electronic Claims (837P) the Rendering Provider information is placed within the 2310B loop (NM108=XX NM109 = NPI).
  • For the CMS-1500 version 02/12, the Rendering Provider should be placed in Box 31 and the NPI should be placed in Box 24J (unshaded) for each service line billed. 

Note: The Bill-To Provider is considered to be the Rendering Provider if the Rendering Provider information is left blank/null. 

5. WellCare strongly encourages that billers include the taxonomy code on file with the State Medicaid program for the services associated to the Rendering Provider or the FQHC/RHC.

  • For Electronic Claims (837P) - when a Rendering provider loop is billed, the Rendering Taxonomy is placed in the 2310C loop in the PRV segment. If the Rendering Provider is left blank/null, then the Bill-To Taxonomy should be billed in the 2000A loop within the PRV segment.
  • For the CMS-1500 version 02/12, the Taxonomy code associated to the Rendering Provider billed in Box 31 is placed within Box 24J (shaded) for each line billed on the claim. Box 24I (shaded) must include a PXC or ZZ qualifier code for each line that is billed. If no rendering provider is placed in Box 31, then the Taxonomy Code should be placed in Box 33b. This Taxonomy Code will be associated to the NPI billed in Box 33a. 

6. Always include all CPT Codes for services you are billing.

  • If your contract is for a T-Code, your claim must have a T-Code in addition to the CPT Codes. You will receive the flat rate per your contract, but CPT Codes track your HEDIS® services, which may affect your total reimbursement or ongoing participation as a network provider. 

7. Always make sure providers in your clinics have WellCare credentials to receive payment under your contract.

  • All providers working in your clinics who are billing for services must be credentialed by WellCare to be treated as a participating provider and receive payment under your contract. The easiest credentialing process is to participate in CAQH. Please ensure all information in CAQH is current, unexpired and that each provider has a current attestation not greater than 90 days old. 

8. Submit Electronic Claims for Free to WellCare (for faster and the most accurate adjudication).

  • Call our preferred EDI partner, RelayHealth (McKesson), at 1-877-411-7271. EDI Payor ID: 14163 Fee for Service (chargeable submissions). 

9. Sign up for free Electronic Fund Transfer (for fast payments and remittance advice).

10. Visit our Provider Resources area for more information.
You'll find our Quick Reference Guide for contact information, authorization requirements and more.

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Last Updated On: 7/12/2016