FQHC PPS Rate & Same-Day Service Scrubber

Under Medicare and Medicaid Prospective Payment Systems (PPS), Federally Qualified Health Centers bill bundled all-inclusive rates adjusted by local Geographic Adjustment Factors (GAF). Scrub your qualifying encounter codes (G0466–G0470), validate same-day mental health statutory exceptions (Modifier 59/XE), and model supplemental Medicaid wrap-around reconciliations.

FQHC Prospective Payment System Configuration

CMS-1450 (UB-04) Bill Type 771 Encounter Parameters

Geographic Adjustment Factor (GAF) Location

CMS CY 2025/2026 Base Rate: $195.65 × GAF (1.000)

Primary Qualifying Encounter Code

UB-04 Rev Code: 0521

Same-Day Secondary Encounter

Did the patient receive a second distinct service on the same date?

Secondary Encounter Scenario

Secondary Mental Health Code

Medicaid MCO Wrap-Around Reconciliation

Primary Medicaid MCO Paid Amount ($)

Typical fee-for-service / capitation rate paid by MCO

Sliding Fee Discount Tier

42 U.S.C. § 254b(k)(3)(G) SFDS Compliance

Reimbursement Scrubber ResultsCMS-1450 Bill 771

Primary Encounter (G0467):$195.65

Secondary Encounter (G0470):+$195.65

Total Gross PPS Allowable:$391.30

MCO Paid Amount:-$85.00

Supplemental Medicaid Wrap:+$306.30

Qualifying Encounter Validation Passed

QUALIFIED for dual PPS encounter reimbursement under 42 CFR § 405.2463(b). Medical (0521) and Mental Health (0900) services delivered on same date are statutory exceptions.

Required Modifier: 59 or XE (Separate Revenue Line 0900)

Get Full FQHC / RHC Revenue Audit

ANSI X12 837I / UB-04 EDI Segment Mapping

Institutional Type of Bill 771 Revenue Code Lines

ISA*00* *00* *ZZ*SUBMITTER *ZZ*CMS-MAC *260905*1030*^*00501*000000001*0*P*:~ GS*HC*SUBMITTER*RECEIVER*20260905*1030*1*X*005010X223A2~ ST*837*0001*005010X223A2~ BHT*0010*00*20260905001*20260905*1030*CH~ NM1*41*2*VALLEY COMMUNITY HEALTH CENTER*****XX*1992837461~ CLM*FQHC-CLAIM-001*391.30***771:A:1*Y*A*Y*Y~ // LINE 1: PRIMARY PPS QUALIFYING ENCOUNTER LX*1~ SV2*0521*HC:G0467*195.65*UN*1~ DTP*472*D8*20260905~ // LINE 2: SECONDARY SAME-DAY STATUTORY EXCEPTION ENCOUNTER LX*2~ SV2*0900*HC:G0470:59*195.65*UN*1~ DTP*472*D8*20260905~ // CMS EXCEPTION ATTESTATION: SAME-DAY MEDICAL + MENTAL HEALTH SPLIT SE*14*0001~ GE*1*1~ IEA*1*000000001~

Request Official FQHC / RHC Revenue Scrubber Review

Have our community health RCM team run 30 days of claims through our deep PPS validation engine.

Next Step For Your Practice

Turn these FQHC PPS Rate Scrubber insights into recovered cash

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