For federally qualified health centers, Look-Alikes and community health center networks with medical, behavioral health and dental sites.
Health centers rarely lose the most money on denials they can see. They lose it on wraparound nobody files, same-day mental health visits folded into a medical visit, and new patients billed as established. A new patient visit pays 1.3416 times the $207.72 Medicare base rate for 2026. Medicare Advantage wraparound claims were never filed for 23% of eligible MA visits in the Luxen claim audit. Luxen bills G0466 to G0470, reconciles every wraparound and works inside your EHR.
On this page
FQHC billing services code, submit and reconcile encounter claims for federally qualified health centers: Medicare PPS visits on G0466 to G0470, Medicaid PPS and wraparound from managed care plans. The 2026 Medicare base rate is $207.72 per visit. Visits billed under the wrong rendering provider caused 8% of RHC and FQHC denials in the Luxen claim audit.
Encounter rate claims change with the site and the service line.
We also bill hospital visits by health center practitioners, which Medicare does not pay as FQHC visits.
Most health center losses are underpayments, not denials. Figures use the 2026 Medicare PPS base rate of $207.72 before the geographic adjustment factor.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Medicare Advantage visit paid below PPS | G0466 to G0470 on revenue code 0519, TOB 77X | Supplemental wraparound claim never sent to the MAC | PPS rate minus MA payment: $207.72 minus a $170.00 MA payment is $37.72 | Medicare Advantage wraparound claims were never filed for 23% of eligible MA visits |
| Medical and mental health visit on the same day | G0467 plus G0470 | Billed as one visit | $207.72 | Same-day medical and mental health visits were billed as a single visit on 12% of qualifying days |
| New patient billed as established | G0466, not G0467 | The 1.3416 new patient adjustment is missed | $70.96 ($278.68 against $207.72) | Coding and modifier errors caused 21% of denials |
| Visit sent under the wrong site or practitioner | Any G code, site CCN and rendering NPI | Practitioner not linked to the enrolled site | $207.72 | Visits billed under the wrong rendering provider caused 8% of RHC and FQHC denials |
| Telehealth visit on or after October 1, 2026 | Individual CPT or HCPCS code with 95 or 93, not G2025 | G2025 still sent after the switch | $97.53, the 2026 G2025 rate | Date of service checked before release |
| Care management in 2026 | Individual care management codes, not G0511 | Terminated code rejects | The national non-facility fee schedule rate for the code | Retired G0511 still appeared on 9% of 2026 FQHC care management claims |
Health centers bill Medicare on the institutional claim with type of bill 77X. The G code sets the payment; the CPT and HCPCS lines under it show what was done.
| Code | Visit | Revenue code | Payment basis |
|---|---|---|---|
| G0466 | New patient medical visit | 052X or 0519 | PPS rate times 1.3416 |
| G0467 | Established patient medical visit | 052X or 0519 | PPS rate |
| G0468 | IPPE or annual wellness visit | 052X or 0519 | PPS rate times 1.3416 |
| G0469 | New patient mental health visit | 0900 or 0519 | PPS rate times 1.3416 |
| G0470 | Established patient mental health visit | 0900 or 0519 | PPS rate |
Revenue code 0519 is used only on Medicare Advantage supplemental claims. Our medical coding service checks that the G code, revenue code and CPT lines agree before release.
A visit is a medically necessary medical or mental health encounter with a health center practitioner: physician, NP, PA, certified nurse midwife, clinical psychologist or clinical social worker, and since January 1, 2024, marriage and family therapists and mental health counselors. Mental health visits count when furnished by real-time audio and video or audio-only. Services and supplies incident to the visit are included in the PPS payment.
Medicare pays each health center a national base rate, $207.72 for 2026, up 2.5% from $202.65 in 2025, multiplied by its FQHC geographic adjustment factor (GAF). New patients, IPPEs and annual wellness visits get a further 1.3416 adjustment. Medicare pays 80% of the lesser of the line charge or the PPS rate.
| Visit, GAF of 1.000 | PPS rate | Patient coinsurance (20%) | Medicare pays (80%) |
|---|---|---|---|
| Established patient, G0467 | $207.72 | $41.54 | $166.18 |
| New patient, G0466 | $278.68 | $55.74 | $222.94 |
If a line charge sits below the PPS rate, both Medicare payment and coinsurance fall to the charge, so a stale charge master cuts every visit.
The Part B deductible, $283 in 2026, does not apply to FQHC-covered services. Coinsurance is 20% of the lesser of the charge or the PPS rate.
When a Medicare Advantage plan pays less than the health center PPS rate, Medicare pays the difference as a supplemental wraparound: PPS rate minus MA contract rate. The CMS manual example is a $225 PPS rate and a $200 MA rate, a $25 wraparound. There is no wraparound when the MA rate is higher, and plan bonuses, risk pool payments and withholds do not count toward the MA payment.
The supplemental claim goes to the MAC on TOB 77X with revenue code 0519 after the MA plan pays. Our denials and AR recovery team works every supplemental claim that comes back unpaid or short.
Section 702 of BIPA 2000 added Section 1902(bb) to the Social Security Act, which requires state Medicaid programs to pay FQHCs a per-visit PPS rate. The rate rises each year by the Medicare Economic Index and is adjusted when the health center scope of services changes. A state may use an alternative payment method only when the health center agrees and the payment is at least what PPS would pay.
Visit definitions, rate codes and reconciliation schedules differ by state. See medical billing in Arkansas, medical billing in Maine and medical billing in New Mexico.
When a Medicaid managed care plan pays less than the PPS rate, the state owes the health center the difference as a supplemental payment. That money arrives only when each MCO payment is matched to the visit. Underpayments against contracted rates appeared on 7.8% of paid claims in the Luxen claim audit, and wraparound shortfalls sit in the same remittances.
Health Center Program grantees must give:
For a family of four in the 48 contiguous states, the 2026 guidelines put 100% at $33,000 and 200% at $66,000. Our patient billing service applies the right discount tier before a statement goes out. Plain-language statements plus text reminders raised patient collections 22% across 14 practices (Luxen client data).
Medicare counts every encounter on one day as a single FQHC visit, except a medical plus a mental health visit, or an illness or injury after the first visit (Medicare Benefit Policy Manual, Chapter 13, section 40.3). A mental health visit folded into the medical claim gives away $207.72 before the GAF. Coding and modifier errors caused 21% of denials (Luxen claim audit).
Medicare pays a national per-visit rate adjusted by the GAF, at 80% of the lesser of the charge or the PPS rate (42 CFR 405.2410; CMS MM14309). The average underpaid claim was short by $38 (Luxen claim audit).
Marriage and family therapists and mental health counselors became FQHC practitioners on January 1, 2024, alongside clinical psychologists and clinical social workers (CMS CY 2024 physician fee schedule final rule). Each still needs Medicare enrollment, and credentialing lapses delayed payment for 1 in 12 providers added in the prior year (Luxen billing reviews).
FQHC-covered services carry no Part B deductible, which is $283 in 2026 (Benefit Policy Manual, Chapter 13, section 90; CMS 2026 Part B fact sheet). Practices lost 3.1% of collections to patient balances written off before a second statement (Luxen client data).
Medicare also pays a supplemental wraparound when a Medicare Advantage plan pays below the PPS rate, billed to the MAC with revenue code 0519 (Medicare Claims Processing Manual, Chapter 9, section 60.5). Timely filing caused 6% of denials, and only 4% of those were recovered (Luxen claim audit).
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
We work inside the systems your health center already runs, with no migration.
We sign the BAA before access.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Luxen claim audit, 61,400 claims audited from Jan 2025 to Jun 2026, including 4,800 FQHC claims:
Luxen client data, 38 client practices, Jan 2024 to Jun 2026:
Managed-care encounters and supplemental payments were never reconciled at the patient level. Luxen identified 203 unmatched encounters and recovered $92,400 that was missing from our payment records.
Chief Financial Officer, multi-site federally qualified health center
Claims from our medical, dental, and behavioral health sites were rejecting for different combinations of location, provider, and encounter information. Luxen standardized the setup by payer and reduced front-end rejections from 15% to 3%.
Revenue Cycle Director, community health center network
Full engagements are written up in our dental practice case study and our ambulance billing case study.
The Consolidated Appropriations Act, 2026 keeps health centers as Medicare distant site telehealth providers through December 31, 2027. For dates of service on or after October 1, 2026, CMS requires the individual CPT or HCPCS code for the service instead of G2025, with modifier 95 for audio and video or 93 for audio-only. G2025 pays $97.53 for 2026 dates before the switch. The in-person visit requirement for mental health visits by telecommunications will not take effect until after January 1, 2028.
Starting January 1, 2025, CMS required health centers to bill the individual CPT or HCPCS codes for care coordination services instead of G0511, with a transition period. G0511 is terminated, and G0512 and G0071 are no longer reportable from January 1, 2026. Care management services are paid at the national non-facility physician fee schedule rate. APCM codes G0556 to G0558 and the behavioral health add-ons G0568 to G0570 are available to health centers. Retired G0511 still appeared on 9% of 2026 FQHC care management claims in the Luxen claim audit.
For dates of service on or after July 1, 2025, health centers report pneumococcal, influenza, hepatitis B and COVID-19 vaccines and their administration on the claim at the time of service, instead of waiting for the cost report.
| Item | Rule | Deadline |
|---|---|---|
| Medicare cost report | Form CMS-224-14 | Last day of the fifth month after the cost reporting period ends |
| UDS report to HRSA | Prior calendar year data | January 1 to February 15 |
| New service location | Form CMS-855A, separate enrollment and CCN for each location | Before billing Medicare from that location |
| New MFT or mental health counselor | Medicare enrollment, linked to each site | Before their visits are billed |
Our credentialing team tracks every site and practitioner enrollment. A lapsed re-credentialing held payments for a median of 47 days (Luxen billing reviews).
Practices that reviewed AR ageing monthly carried 12 fewer days in AR (Luxen billing reviews).
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections. No setup or exit fee.
A health center collecting $150,000 a month:
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% |
|---|---|---|---|
| Medical visits (Medicare, Medicaid, commercial) | $95,000 | $2,850 | $5,700 |
| Behavioral health visits | $30,000 | $900 | $1,800 |
| Dental | $15,000 | $450 | $900 |
| MA and Medicaid wraparound | $10,000 | $300 | $600 |
| Total | $150,000 | $4,500 | $9,000 |
| Cost | In-house | Luxen |
|---|---|---|
| Monthly | $11,850 (7.9% of collections) | $4,500 to $9,000 |
| Annual | $142,200 | $54,000 to $108,000 |
| When a biller leaves | Open biller roles took a median 67 days to fill | No gap in coverage |
| Terms | Salaries, benefits and software | Month to month, 30 days notice |
Fully loaded in-house billing cost 7.9% of collections for practices under $2M, across 96 practices that shared payroll data (Luxen billing reviews).
| Partner type | PPS and wraparound | Same-day and mental health visits | Reporting | Terms |
|---|---|---|---|---|
| In-house biller | Depends on one person | Tracked by hand | Built by staff | Payroll and turnover |
| Generalist billing company | Fee-for-service workflow | Often billed as one visit | Standard aging | Often annual |
| Specialty billing company | Encounter billing, wraparound varies | Usually handled | Varies | Varies |
| EHR vendor RCM | Vendor claim rules | Depends on EHR setup | Vendor platform | Bundled with software |
| Luxen | Certified coders reconcile PPS, MA and Medicaid wraparound | Checked against documentation before release | Monthly denials, wraparound and AR by payer | Month to month, 30 days notice |
Compare medical billing companies on these points, or see what full-service medical billing covers.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Medicare pays health centers per visit, not per CPT code, on type of bill 77X with G0466 to G0470. The 2026 base rate of $207.72 is adjusted by a geographic factor, and by 1.3416 for new patients and wellness visits. Medicaid pays its own PPS, and wraparound is owed when a managed care plan pays less.
Luxen charges 3% to 6% of collections, month to month with 30 days notice and no setup or exit fee. For a health center collecting $150,000 a month, that is $4,500 to $9,000. Fully loaded in-house billing cost 7.9% of collections for practices under $2M in Luxen billing reviews.
About 2 weeks from signed BAA to working claims; the median time from signed BAA to first claims worked was 9 business days (Luxen client data). We start with the oldest money, including unfiled Medicare Advantage and Medicaid wraparound, and first recovered payments arrived a median of 17 days after work began. You keep your EHR and your enrollments.
Yes. We work inside your existing system, including OCHIN Epic, NextGen, eClinicalWorks and athenaOne, with no migration. We check that each site, rendering practitioner and G code maps correctly on the 77X claim, since visits billed under the wrong rendering provider caused 8% of RHC and FQHC denials in our claim audit.
Yes. Medicare pays two visits when a patient has a medical visit and a mental health visit the same day, billed with a medical G code such as G0467 and a mental health G code such as G0470 on revenue code 0900. A later illness or injury the same day also counts; all other same-day encounters are one visit under Benefit Policy Manual Chapter 13, section 40.3.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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