Products & Programs Long-Term Services & SupportsMedicare AdvantageHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingFebruary 21, 2025

Reminder of claims submissions for FQHCs/RHCs for T1015

We would like to remind federally qualified health center (FQHC) providers of when to use the T1015 — clinic, visit/encounter, all‑inclusive code, to report valid medical encounter visits that would be eligible for wrap payments.

Ensure the claim includes a valid encounter code, which can be found on the Myers & Stauffer website: Medicaid and Medicare Auditing and Attest Services Provider Portal | Myers & Stauffer.

For members with Anthem as primary insurance or commercial primary coverage, follow these Indiana Health Coverage Programs (IHCP) billing guidelines:

  • Use the CMS‑1500 claim form.
  • Include place-of-service codes 02, 03, 04, 10, 11, 12, 31, 32, 50, or 72.
  • Include the T1015 code if the encounter code is valid.

Secondary claims are claims that were first submitted to the commercial payer and are then submitted to Anthem. Secondary claims require the T1015. Anthem is required to pay any amount not paid by the commercial payer up to the IHCP fee schedule amount. Amounts paid by the commercial payer that exceed the IHCP fee schedule should be in a pay status at $0 so that wrap payment can be made.

Claims must include T1015 with a valid encounter code or they will not be processed for payment.

For Medicare or Medicare Advantage (crossover) claims (members eligible for both Medicare and Medicaid):

  • No longer required to include T1015 for dates of service on or after July 1, 2021.
  • Bill on the institutional UB‑04 form, as required by Medicare.
  • Anthem accepts institutional claims that automatically cross over from Medicare but use the CMS‑1500 form for claims not automatically crossed over.
  • Anthem is responsible for paying the co‑insurance/deductible amount for FQHC/rural health clinic (RHC) claims.

Medicare payments for FQHCs are applied to the FQHC Payment Code service line with revenue code 052X (medical visits) and revenue code 0900 (mental health visits). RHCs use revenue codes 052X (medical) and 0900 (mental health).

The Anthem payment applies only to the coinsurance, copayment, and deductible amounts for the FQHC Payment Code line, which are represented by specific G codes. There is no payment application to informational Qualifying Visit codes. Qualifying FQHC Payment Codes are listed in Table 1.

Table 1 — Qualifying Medicare FQHC/RHC payment codes and qualifying visit codes

HCPCS code

Description

G0466

A medically necessary, face‑to-face (one‑on-one) encounter between a new patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving medical services; a new patient is one who has not received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within the past three years prior to the date of service

G0467

A medically necessary, face‑to-face (one‑on-one) encounter between an established patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving medical services; an established patient is one who has received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within three years prior to the date of service

G0468

A FQHC visit that includes an initial preventive physical exam (IPPE) or annual wellness visit (AWV) and includes the typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving an IPPE or AWV, including all services that would otherwise be billed as a FQHC visit under G0466 or G0467

G0469

A medically necessary, face‑to-face (one‑on-one) mental health encounter between a new patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving a mental health visit

G0470

A medically necessary, face‑to-face (one‑on-one) mental health encounter between an established patient and a qualified FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of services that would be furnished per diem to a Medicare beneficiary receiving a mental health visit; an established patient is one who has received any professional medical or mental health services from any practitioner within the FQHC organization or from any sites within the FQHC organization within three years prior to the date of service

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

INBCBS-CDCR-075255-24

PUBLICATIONS: March 2025 Provider Newsletter