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Federally Qualified Health Center/Rural Health Clinic

CHIP Differential Rate Request Form


The Children’s Health Insurance Program (CHIP) Differential Rate Request forms are designed to establish an interim rate that reimburses a provider for the difference between their prospective payment system (PPS) rate and their Healthy Family Program (HFP) plans average reimbursement per visit for CHIP beneficiaries. The information provided on these forms is subject to the Medicare Reasonable Cost Principles in 42 CFR, Part 413 in accordance with the State’s Federally Qualified Health Center (FQHC) / Rural Health Clinic (RHC) State Plan Amendment.

Submitted forms must be complete, legible, and signed to be accepted. Forms received that are not clear, legible, are altered, incomplete, and/or not signed will be returned to the provider to make the correction. If the forms are returned, instructions will be enclosed noting the deficiency and corrective action needed.
Submit the completed CHIP Differential Rate Request forms to:
Department of Health Care Services

Financial Audits Branch

Audit Review and Analysis Section

1500 Capitol Avenue – MS 2109

P.O. Box 997413

Sacramento, CA 95899-7413

For assistance in completing these forms or any other questions, you may contact the Audit Review and Analysis Section via email to

Billing Code 19:

Only FQHC/RHC providers providing services to CHIP beneficiaries are to bill code 19.

The reported data on this form is subject to field review by the Department and must be supported by the appropriate documentation.

(Related to DHCS 3105 – Tab “Worksheet 1”)

Complete Part A, lines 1 through 7 with the requested information. If you need additional space to identify entities that you own, attach a page with the provider name, location, and clinic provider number. Complete Part B, Certification Statement with the requested information. The individual signing this statement must be an officer or other authorized responsible person. An original signature is required.


(Related to DHCS 3105 – Tabs “Sheet1”, “Sheet2” and “Sheet3”)

Enter the FQHC/RHC legal name, National Provider Identifier (NPI), and fiscal period.
FQHC/RHC Name: Print the FQHC/RHC legal name that appears on the Medi-Cal license
NPI Number: Print the NPI number used to bill the Medi-Cal program for this site.
Fiscal Period: Print the fiscal period for which you are reporting data.
Healthy Family Plans
Plan Name: Enter the name of Healthy Family Plans under columns A through E in DHCS 3105 tab “Sheet1” and identify Payment and visit information for each plan as explained below. Same for DHCS 3105 tabs “Sheet2” columns F through J, & “Sheet3” columns K through O.

Payment Information
A: List the capitation payments you received or expect to receive from each HFP plan. Identify the Plan and its name (Health, dental, vision, etc.). List all payments received, not only those corresponding to visits incurred.
B: List any other form of payment you received or expect to receive from HFP plan other than those in (A) above and specify the type of payment and name of plan (e.g. fee-for-service, negotiated, etc.).
Visit Information
A: List the HFP plan visits for CHIP beneficiaries for capitated payments.

B: List the HFP plan visits for CHIP beneficiaries for non-capitated payments.

Note: The definition of a visit for CHIP beneficiaries is the same as that for Medi-Cal beneficiaries. For a visit to be billed under code 19, it should meet the criteria of a visit applied in setting Medi-Cal PPS rate. For example, immunizations, health education encounters, prescription refill encounters do not constitute a visit and should not be billed to code 19 even though they are covered HFP benefits.
Total visits include all visits for all payor types meeting the definition below REGARDLESS of whether such visits were billed and/or paid.
A “visit” for purposes of reimbursing an FQHC or RHC services is any of the following:
(a) A face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker, or visiting nurse, hereafter referred to as a “health professional,” to the extent the services are reimbursable as covered benefits described in section 1905(a)(2)(C) of the Social Security Act (the Act) that are furnished by an FQHC or services described in section 1905(a)(2)(B) of the Act that are furnished by an RHC. The definition of “physician” includes the following:

  1. A doctor of medicine or osteopathy authorized to practice medicine and surgery by the State and who is acting within the scope of his/her license.

  2. A

    doctor of podiatry authorized to practice podiatric medicine by the State and who is acting within the scope of his/her license.

  3. A doctor of optometry authorized to practice optometry by the State and who is acting within the scope of his/her license.

  4. A doctor of chiropractics authorized to practice chiropractics by the State and who is acting within the scope of his/her license.

  5. A doctor of dental surgery (dentist) authorized to practice dentistry by the State and who is acting within the scope of his/her license.

Inclusion of a professional category within the term “physician” is for the purpose of defining the professionals whose services are reimbursable on a per visit basis, and not for the purpose of defining the types of services that these professionals may render during a visit (subject to the appropriate license).

(b) Comprehensive perinatal services when provided by a comprehensive perinatal services practitioner as defined in the California Code of Regulations, title 22, Section 51179.7.
(c) Adult Day Health Care (ADHC) services when all of the following requirements are met:

  1. ADHC services are provided pursuant to the requirements of California Code of Regulations, title 22, chapter 5, articles 1 through 5 (commencing with section 54001, including section 54113, which requires four or more hours of ADHC services per day be provided).

  1. An FQHC or RHC providing the ADHC services has received approval from the federal Health Resources and Services Administration (HRSA) to provide ADHC services to the extent required by law.

  1. The ADHC services are included in the State Plan.


ncounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit. More than one visit may be counted on the same day (which may be at a different location) in either of the following situations:
(a) When the clinic patient, after the first visit, suffers illness or injury requiring another diagnosis or treatment, two visits may be counted.
(b) The clinic patient is seen by a dentist and sees any one of the following providers: physician (as defined above in PART B (a)(i)-(v)), physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services practitioner or ADHC provider.

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DHCS 3105i (10/2010)

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