TL;DR
Chapter 13 of the Medicare Benefit Policy Manual covers rural health clinic and federally qualified health center services. It explains what counts as a billable visit, the all-inclusive rate for RHCs and the prospective payment system for FQHCs, the same-day visit rule and its exceptions, which practitioners' services are included, and how care management, virtual communication, mental health and telehealth services are paid.
Chapter 13 at a glance
- Current revision
- Rev. 13600
- Issued February 20, 2026
- Effective
- January 1, 2026
- Implemented March 23, 2026
- Sections
- 89
- 25 top-level sections
- Transmittals in history
- 17
- Listed at the end of the chapter
- Monthly searches
- 50
- Google Ads, US, October 2026
What chapter 13 governs for billing
Sections 10 to 30 cover what RHCs and FQHCs are and the location and staffing requirements they must meet. Section 40 defines the visit: a medically necessary face-to-face, or for mental health in some cases telecommunications, encounter with an RHC or FQHC practitioner. Encounters with more than one practitioner on the same day, or several with one practitioner, count as a single visit regardless of length or complexity (40.3), with exceptions for an illness or injury that occurs later the same day, reported with modifier 59 or 25, and for certain combinations such as a medical visit and a mental health visit. Section 40.5 applies the payment window to provider-based clinics.
Section 70 explains payment. RHCs are paid an all-inclusive rate per visit, subject to payment limits whose rules differ for independent and provider-based clinics (70.1 and 70.2), and FQHCs are paid under a prospective payment system rate adjusted for geography and for new patients and certain preventive visits (70.3), billed with FQHC payment codes (70.4). Sections 80 and 90 cover cost reports, coinsurance and deductible waivers, and section 100 the commingling rules for clinics that share space with other practices.
Sections 110 to 250 define the services. Physician, nurse practitioner, physician assistant and nurse-midwife services and the services incident to them are RHC or FQHC services (110 to 140), as are clinical psychologist, clinical social worker, marriage and family therapist and mental health counselor services (150 to 170). Telehealth (200) explains that, through December 31, 2026, clinics may bill non-behavioral health visits furnished through telecommunications with HCPCS code G2025, while care management services (230), virtual communication (240) and intensive outpatient program services (250) have their own billing rules.
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 13 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 40.3 | Multiple Visits on Same Day | Multiple visits on the same day are one visit, except for the listed circumstances. |
| 40.5 | 3 Day Payment Window | The payment window for provider-based RHCs and FQHCs. |
| 70.1 | RHCs Billing Under the AIR | RHCs billing under the all-inclusive rate. |
| 70.3 | FQHC PPS Payment Rate and Adjustments | The FQHC prospective payment system rate and its adjustments. |
| 170 | Mental Health Visits | Mental health visits, including those furnished through telecommunications. |
| 200 | Telehealth Services | Telehealth services and the G2025 billing rule through 2026. |
| 230 | Care Management Services | Care management services in RHCs and FQHCs. |
How chapter 13 shows up on claims and denials
Because the visit is the unit of payment, most RHC and FQHC problems are bundling problems. A second encounter on the same day is paid as part of the first unless it meets an exception and carries the required modifier, and services that are part of the visit are not paid separately, which shows up as reason code 97. Services that are not RHC or FQHC services, such as technical components billed under the wrong number, must go on a different claim.
Care management and virtual communication services follow their own codes and rules in sections 230 and 240, and telehealth visits through 2026 use G2025. Claims that mix these with face-to-face visits incorrectly, or omit required line-level HCPCS codes, return reason code 16 or 4 depending on the error.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 97 | Claim adjustment reason code | Service included in the payment for the visit already adjudicated. |
| 16 | Claim adjustment reason code | Missing line-level HCPCS or other required information. |
| 4 | Claim adjustment reason code | Modifier such as 59 or 25 inconsistent with the visit billed. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13600, issued February 20, 2026, effective January 1, 2026, implemented March 23, 2026 (change request 14363). That revision changed sections 50.1 (RHC Services), 120.1 (Provision of Incident to Services and Supplies), 120.2 (Incident to Services and Supplies Furnished in the Patient's Home or Location Other than the RHC or FQHC), 140 (Services and Supplies Furnished Incident to NP, PA, and CNM Services), 160 (Services and Supplies Incident to CP, CSW, MFT and MHC Services), 170 (Mental Health Visits), 200 (Telehealth Services), 220.1 (Preventive Health Services in RHCs). Its subject line reads: “Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update for Calendar Year (CY)”.
The newest rows of the transmittal history printed at the end of the chapter (17 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R13600BP | February 20, 2026 | Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update for Calendar Year (CY) | 14363 |
| R13547BP | December 18, 2025 | Revisions to Publication 100-04, Medicare Claims Processing Manual, Chapters 9, 18, and Publication 100-02, Medicare Benefit Policy Manual, Chapter 13 To Include Updated Information | 14254 |
| R12832BP | September 12, 2024 | Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update | 13493 |
| R11803BP | January 26, 2023 | Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update | 13063 |
| R10729BP | April 26, 2021 | Updates to Medicare Benefit Policy Manual for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services (Manual Updates Only) | 12252 |
| R252BP | December 7, 2018 | Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update | 11019 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 50.1 | RHC Services | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 120.1 | Provision of Incident to Services and Supplies | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 120.2 | Incident to Services and Supplies Furnished in the Patient's Home or Location Other than the RHC or FQHC | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 140 | Services and Supplies Furnished Incident to NP, PA, and CNM Services | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 160 | Services and Supplies Incident to CP, CSW, MFT and MHC Services | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 170 | Mental Health Visits | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 200 | Telehealth Services | Rev. 13600, February 20, 2026; effective January 1, 2026 |
| 220.1 | Preventive Health Services in RHCs | Rev. 13600, February 20, 2026; effective January 1, 2026 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 RHC and FQHC General Information · p. 7 · 2 subsections
- Open section 10 in the PDF
- 10.1 RHC General Information · p. 7
- 10.2 FQHC General Information · p. 8
20 RHC and FQHC Location Requirements · p. 10 · 2 subsections
- Open section 20 in the PDF
- 20.1 Non-Urbanized Area Requirement for RHCs · p. 11
- 20.2 Designated Shortage Area Requirement for RHCs · p. 11
30 RHC and FQHC Staffing Requirements · p. 12 · 3 subsections
- Open section 30 in the PDF
- 30.1 RHC Staffing Requirements · p. 12
- 30.2 RHC Temporary Staffing Waivers · p. 13
- 30.3 FQHC Staffing Requirements · p. 14
40 RHC and FQHC Visits · p. 14 · 5 subsections
- Open section 40 in the PDF
- 40.1 Location · p. 15
- 40.2 Hours of Operation · p. 16
- 40.3 Multiple Visits on Same Day · p. 16
- 40.4 Global Billing · p. 17
- 40.5 3 Day Payment Window · p. 18
50 RHC and FQHC Services · p. 18 · 3 subsections
- Open section 50 in the PDF
- 50.1 RHC Services · p. 18
- 50.2 FQHC Services · p. 19
- 50.3 Emergency Services · p. 20
60 Non RHC/FQHC Services · 1 subsections
- Open section 60 in the PDF
- 60.1 Description of Non RHC/FQHC Services · p. 21
70 RHC and FQHC Payment Rate · p. 22 · 8 subsections
- Open section 70 in the PDF
- 70.1 RHCs Billing Under the AIR · p. 23
- 70.2 RHC Payment Limit and Exceptions · p. 23
- 70.2.1 Payment Limits Applicable to Independent RHCs, and Provider-Based RHCs in a Hospital with 50 or More Beds, and New RHCs · p. 24
- 70.2.2 Payment Limits Applicable to Provider-Based RHCs in a Hospital with Less than 50 Beds · p. 25
- 70.2.2.1 Determining Payment Limits for Specified (that is, Grandfathered) Provider-Based RHCs with an AIR Established for RHC Services Furnished in 2020 · p. 25
- 70.2.2.2 Determining Payment Limits for Specified (that is, Grandfathered) Provider-Based RHCs that did not have an AIR Established for RHC Services Furnished in 2020 · p. 26
- 70.3 FQHC PPS Payment Rate and Adjustments · p. 27
- 70.4 FQHC Payment Codes · p. 27
80 RHC and FQHC Cost Reports · p. 28 · 4 subsections
- Open section 80 in the PDF
- 80.1 RHC and FQHC Cost Report Requirements · p. 28
- 80.2 RHC and FQHC Consolidated Cost Reports · p. 30
- 80.3 RHC and FQHC Cost Report Forms · p. 30
- 80.4 RHC Productivity Standards · p. 31
90 RHC and FQHC Charges, Coinsurance, Deductible, and Waivers · p. 31 · 2 subsections
- Open section 90 in the PDF
- 90.1 Charges and Waivers · p. 32
- 90.2 Sliding Fee Scale · p. 32
100 Commingling · p. 32
110 Physician Services · 3 subsections
- Open section 110 in the PDF
- 110.1 Dental, Podiatry, Optometry, and Chiropractic Services · p. 34
- 110.2 Treatment Plans or Home Care Plans · p. 35
- 110.3 Graduate Medical Education · p. 35
120 Services and Supplies Furnished "Incident to" Physician's Services · p. 35 · 3 subsections
- Open section 120 in the PDF
- 120.1 Provision of Incident to Services and Supplies · p. 36
- 120.2 Incident to Services and Supplies Furnished in the Patient's Home or Location Other than the RHC or FQHC · p. 37
- 120.3 Payment for Incident to Services and Supplies · p. 38
130 Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services · p. 38 · 3 subsections
- Open section 130 in the PDF
- 130.1 NP, PA, and CNM Requirements · p. 39
- 130.2 Physician Supervision · p. 39
- 130.3 Payment to Physician Assistants · p. 39
140 Services and Supplies Furnished Incident to NP, PA, and CNM Services · p. 40
150 Clinical Psychologist (CP) and Clinical Social Worker Services (CSW), Marriage and Family Therapist(MFT), and Mental Health Counselor (MHC) Services · p. 40
160 Services and Supplies Incident to CP, CSW, MFT and MHC Services · p. 42
170 Mental Health Visits · p. 43
180 Physical Therapy, Occupational Therapy, and Speech Language Pathology Services · p. 44
190 Visiting Nursing Services · p. 45 · 5 subsections
- Open section 190 in the PDF
- 190.1 Description of Visiting Nursing Services · p. 45
- 190.2 Requirements for Furnishing Visiting Nursing Services · p. 45
- 190.3 Home Health Agency Shortage Area · p. 46
- 190.4 Authorization for Visiting Nursing Services · p. 46
- 190.5 Treatment Plans for Visiting Nursing Services · p. 46
200 Telehealth Services · p. 47
210 Hospice Services · p. 47 · 2 subsections
- Open section 210 in the PDF
- 210.1 Hospice Attending Physician Services Payment · p. 47
- 210.2 Provision of Services to Hospice Patients in an RHC or FQHC · p. 48
220 Preventive Health Services · p. 49 · 4 subsections
- Open section 220 in the PDF
- 220.1 Preventive Health Services in RHCs · p. 49
- 220.2 Copayment and Deductible for RHC Preventive Health Services · p. 52
- 220.3 Preventive Health Services in FQHCs · p. 53
- 220.4 Copayment for FQHC Preventive Health Services · p. 57
230 Care Management Services · p. 57 · 13 subsections
- Open section 230 in the PDF
- 230.1 Transitional Care Management Services · p. 58
- 230.2 General Care Management Services – Chronic Care Management, Principal Care Management, and General Behavioral Health Integration Services · p. 59
- 230.2.1 Chronic Care Management (CCM) Services · p. 59
- 230.2.2 Principal Care Management (PCM) Services · p. 60
- 230.2.3 Chronic Pain Management (CPM) Services · p. 61
- 230.2.4 General Behavioral Health Integration (BHI) Services · p. 61
- 230.2.5 Remote Patient Monitoring (RPM) Services · p. 61
- 230.2.6 Remote Therapeutic Monitoring (RTM) Services · p. 62
- 230.2.7 Community Health Integration (CHI) Services · p. 62
- 230.2.8 Principal Illness Navigation (PIN) Services · p. 62
- 230.2.9 PIN Peer-Support (PIN-PS) Services · p. 62
- 230.2.10 Payment for General Care Management Services · p. 62
- 230.3 Psychiatric Collaborative Care Model Services · p. 63
240 Virtual Communication Services · p. 67
250 Intensive Outpatient Program (IOP) Services · p. 69 · 1 subsections
- Open section 250 in the PDF
- 250.1 Payment of IOP Services · p. 69
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Benefit Policy Manual chapter 13
QuickAuth coordinates requirement checks, documentation, submission and status tracking with human review, so the coverage conditions in this chapter are looked at before the service. QuickRCM handles claim readiness and the coverage denials that follow.
Frequently asked questions: chapter 13
Can an RHC or FQHC bill two visits on the same day?
Only in the circumstances in chapter 13 section 40.3, such as an illness or injury that occurs after the first visit on the same day, reported with modifier 59 (FQHC) or 59 or 25 (RHC). Otherwise all encounters that day are one visit.
How do RHCs and FQHCs bill telehealth in 2026?
Section 200 explains that, through December 31, 2026, clinics are paid for non-behavioral health visits furnished through telecommunications technology by reporting HCPCS code G2025, including audio-only services.
How are FQHCs paid by Medicare?
Under the FQHC prospective payment system described in chapter 13 section 70.3: a per-visit rate adjusted for geography and for new patients and certain preventive visits, billed with FQHC payment codes.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Benefit Policy Manual, Chapter 13: Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) ServicesVersion Rev. 13600, issued 2026-02-20 · effective 2026-01-01 · file bp102c13.pdfSHA-256 ea551aee86fc8472…
- Medicare Benefit Policy Manual (Pub. 100-02)Version 17 chapter PDFs; newest revision Rev. 13889 (chapter 15), issued 2026-07-30 · effective 2026-09-27 · file 100-02-benefit-policy-manual/*.pdf (17 chapters; SHA-256 of their sha256sum listing)SHA-256 be35772e4f9f80b4…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.