Q&A: Provider-based RHC per visit payment exceptions

Q. What are the exceptions to the per visit payment limit for a provider-based rural health clinic (RHC)?

A. Each CY, CMS establishes a national payment limit per visit for RHC services. In general, the payment limit serves as a cap on the amount an RHC can be paid per visit.

A provider-based RHC may be eligible to receive an exception to the per visit payment limit when either of the following exceptions are met:

• The hospital has fewer than 50 beds as determined under the definition at 42 CFR 412.105(b)
• The hospital’s average daily patient census bed count as described in 42 CFR 412.105(b) does not exceed 40 and the hospital meets both of the following conditions:
  • The hospital has been designated as a sole community hospital or an essential access community hospital
  • The hospital is located in a level 9 or level 10 rural-urban commuting area

The exception to the payment limit per visit only applies during the time in which the RHC meets the applicable requirements for the exception. This exception does not apply to independent RHCs.

For more information, see The Essential Rural Health Clinic Billing and Management Guide.

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