Billing Requirements Reminders for Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs)
Date: 03/26/26
For all claims received on February 26, 2026, Meridian and YouthCare will validate CMS1500/837P claims based on regulatory rules established by Illinois Healthcare and Family Services (HFS) for FQHCs and RHCs.
Providers registered with HFS as provider type 040 and 048, must follow required rules noted in the tables below from the Illinois Association of Medicaid Health Plan’s (IAMHP) Comprehensive Billing Guide section ‘Federally Qualified Health Centers, Rural Health Centers, and Encounter Rate Clinics’, item B “Provider Registration and Billing Requirements”. Visit the IAMHP website to download a copy.
Meridian will validate that the Encounter Rate submission includes T1015, S5190 or T1040 on the first line of the CMS 1500/837P claim form. Additionally, we will validate the registration of the NPI in Box 33a within IMPACT file from HFS to ensure that the provider type 40 or 48 registered NPI is present and active. Meridian will also validate that the correct corresponding taxonomy is present in the billing segment as well or Box 33b. Meridian will continue to require the rendering loop to be present as well for any submissions.
Effective February 26, 2025, claims that fail any of the following validation checks will be denied:
- EXF6 – DENY: BILLING NPI NOT REGISTERED WITH STATE*
- EXG9 – DENY: FQHC CCBHC T1015 S5190 T1040 LINE PLACEMENT VERIFICATION – MUST BE LINE 1**
- EXFd – DENY: FQHC/RHC RENDERING LOOP VERIFICATION – MUST BE PRESENT
- EXRG – DENY: INAPPROPRIATE TAXONOMY SUBMITTED FOR SERVICES PROVIDED
Per the IAMHP Billing Manual
Encounter Rate Submission Guidelines
Paper Claim | HIPAA 5010 837P Loop | HIPAA 5010 837P Segment | Encounter Reimbursement |
|---|---|---|---|
Box 24b | 2300 | CLM05-1 | Place of Service Code |
Box 24f | 2400 | SV1-02 | Encounter rate on initial service line billed with appropriate code, modifier if applicable, and amount. All subsequent service lines with zero dollars, per Section F(ii) above. |
Box 24j | 2310B | NM1-09 | Site NPI or Registered Rendering Provider NPI* |
Box 31 | DOES NOT MAP IN THE 837 | DOES NOT MAP IN THE 837 | Signature of Physician |
Box 32 | 2310C | NM1 | Location where approved encounter service was provided |
Box 33 | 2010AA | NM108=XX | Registered Encounter Clinic Organization Name (not site), billing address, and NPI. Per X12 EDI guidance NO P.O. Boxes or LOCK box permitted in this loop (2010AA) |
2000A | PRV03 | Appropriate taxonomy for the registered provider specialty type in IMPACT:
| |
Pay to Provider | 2010AB | NM1*87 | Pay to Provider Address (P.O. Box or Lock Boxes acceptable in this loop) ** |
*Meridian REQUIRES the Registered Rendering Provider NPI, and will accept either the site NPI or the Registered Rendering Provider NPI.
Encounter billing example using a paper CMS 1500
Fee-for Service Submission Guidelines (requires the provider billing in Box 24j has access to practitioner fee schedule - e.g. labor and delivery at the hospital, provider completing an E&M for inpatient member)
Paper Claim | HIPAA 5010 837P Loop | HIPAA 5010 837P Segment | Encounter Reimbursement |
|---|---|---|---|
Box 24b | 2300 | CLM05-1 | Place of Service Code |
Box 24f | 2400 | SV1-02 | Bill the appropriate procedure code |
Box 24j | 2310B | NM1-09 | Registered Rendering Provider NPI |
Box 31 | DOES NOT MAP IN THE 837 | DOES NOT MAP IN THE 837 |
|
Box 32 | 2310C | NM1 | Location where approved service was provided |
Box 33 | 2010AA | NM108=XX NM109=NPI | Encounter Clinic Organization Name (not site), billing address, NPI, and Registered Rendering Provider taxonomy (as registered in IMPACT): |
Pay to Provider | 2010AB | NM1*87 | Pay to Provider Address (P.O. Box or Lock Boxes acceptable in this loop)* |
Fee-for-Service billing example
Support
For questions, please contact Provider Services at 866-606-3700 or reach out to your Provider Engagement contact. For additional billing requirements, consult the IAMHP Billing Guide (PDF).
CARC/RARC Codes:
*CARC 208 / RARC N257
**CARC 16 / RARC M51
***CARC 16 / RARC N289
****CARC 16 / RARC N255