Handbook for Encounter Clinic Services Chapter D-200 – Policy and Procedures
HFS D-210 (1)
D-210 General Limitations and Considerations on Covered Services
The same policy and procedures that apply to practitioners also apply to the
encounter clinics. Refer to Chapter A-200, Handbook for Practitioners Rendering
Medical Services for detailed department policy regarding medical care.
D-210.1 Definition of Encounter
Encounter services must be rendered in a clinic, patient’s home or long term care
facility if the facility is the patient’s permanent place of residence, or school if the
clinic has a school-based or school-linked specialty. Only one medical encounter
per patient per day can be billed to the department. If the clinic is enrolled for dental
or behavioral health services, only one dental and one behavioral health encounter
per patient per day is eligible for reimbursement.
A billable encounter is defined as one of the following:
Medical face-to-face visit with a physician, physician assistant, midwife, or nurse
practitioner.
Behavioral health face-to-face visit with a licensed clinical psychologist,
licensed clinical social worker, licensed clinical professional counselor, or
licensed marriage and family therapist, as applicable.
• Dental face-to-face visit with a dentist. Dental encounter claims must be
submitted to the department’s dental contractor, DentaQuest. For billing
information, refer to the Dental Office Reference Manual (pdf).
Note: When a service is rendered and does not meet the definition of a medical
encounter visit, a wellness service should be billed to the department for reporting
purposes. In this situation, an encounter procedure code should not be billed and
will not be reimbursed but the services will be documented in the child’s state health
profile. If the claim rejects, the health information will not be documented and the
claim should be rebilled. See appendices for billing information.
D-210.2 Telehealth
Telehealth is the use of a telecommunication system to provide medical services
between places of lesser and greater medical capability and/or expertise, for the
purpose of evaluation and treatment. Medical data exchanged can take the form of
multiple formats: text, graphics, still images, audio and video. The information or
data exchanged can occur in real time (synchronous) through interactive video or
multimedia collaborative environments or in near real time (asynchronous) through
“store and forward” applications. The telecommunication system must, at a
minimum, have the capability of allowing the consulting practitioner to examine the
patient sufficiently to allow proper diagnosis of the involved body system. The
system must also be capable of transmitting clearly audible heart tones and lung
sounds, as well as clear video images of the patient and any diagnostic tools, such