Author: NC Medicaid Provider Reimbursement, (919)-814-0060
In accordance with the North Carolina’s Medicaid State Plan, Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) may request a “rate adjustment due to change in scope of services."
As of April 9, 2018, NC Medicaid instituted a policy regarding Change in Scope of Services. To request a change in scope of service, the provider must submit all necessary documentation in accordance with the change in scope of service policy located at:
• FQHCs: https://medicaid.ncdhhs.gov/providers/programs-services/medical/federally-qualified-health-centers
• RHCs: https://medicaid.ncdhhs.gov/providers/programs-services/medical/Rural-Health-Clinics
Important Dates
Prior to January 1, 2019:
One-time exception: FQHCs/RHCs may submit a change in scope of service request for each unique 12-month cost reporting period in which a qualifying change in scope of service occurred since the base year(s) used to establish the provider’s unique PPS rate. For each change in scope of service requested the provider must be able to fully document costs per Paragraph 3 in the change in scope of service policy. Requested extensions will be reviewed on a case by case basis.
After January 1, 2019:
FQHCs/RHCs may request a change in scope of service once per 12-month period. The request may be based on the first (or subsequent) full year (12-month cost report) in which the cost for the change in scope of service was present.
For providers that have multiple qualifying changes in scope in a single cost report year, please refer to the CISS policy location referenced above.
For an approved CISS rate to be implemented before the beginning of the provider’s fiscal year, the FQHC/RHC must submit the CISS request 90 days prior to the beginning of the provider’s next fiscal year.
The State will evaluate the submitted documentation and notify the FQHC/RHC within 90 days whether the proposed change meets criteria for a change in scope.
The FQHC/RHC’s per-encounter PPS rate will be adjusted to account for increases or decreases in the scope of services and calculated on an incremental basis subject to criteria listed in the change in scope of service policy 4. (a-f). The policy is subject to change on an as-needed and/or annual basis.