![]() Prior Authorizations are required for services rendered out of state for RI Medicaid beneficiaries per RI Code of Regulations, 210-RICR-20-00-3, Chapter 20-Medicaid Payments and Provider.Ī. Payments to providers will not exceed the maximum reimbursement rate of the Medicaid Program. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to Medicaid. Providers must bill the Medicaid Program at the same usual and customary rate as charged to the general public. Prior authorization (PA) is authorization for a procedure or course of treatment obtained before services are rendered. Coding version is determined by date(s) of service. International Classification of Disease, 9th Revision (ICD-9)/10th Revision (ICD-10) is an index of diseases and diagnostic terms to report illnesses, injuries, and reason for encounter with health care providers. HCFA Common Procedure Coding System (HCPCS) is a coding system developed by the Health Care Financing Administration to provide a common system for referencing health care procedures performed under the Medicare and Medicaid programs. Such services must be provided in the most cost effective and appropriate setting and shall not be provided solely for the convenience of the recipient or the service provider.Ĭurrent Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. ![]() Medical Necessity means the medical, surgical or other health services for diagnosis, cure, or treatment, including preventing deterioration of the involved physical or mental condition. Out-of-state hospital providers must follow the same coding guidelines as in-state providers. ![]() Incorrect or incomplete billing of these codes may result in denial or recoupment of reimbursement. The Rhode Island Medicaid program adheres to all code descriptions and limitations regarding age, sex, time, inclusive services and all other guidelines as outlined in the CPT, HCPCS and ICD-9/ICD-10 code books. See Definition Section below for description of these coding structures.Īppropriate usage of CPT, HCPCS and ICD-9/ICD-10 codes is imperative. UB-04 claim forms are submitted with a combination of Revenue Coding codes, International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) diagnosis codes (version based on date(s) of service) and, in certain circumstances, Current Procedure Terminology (CPT), HCFA and Common Procedural Coding System (HCPCS). Refer to the Provider Enrollment page for enrollment information. Professional services provided by hospital-based physicians must be billed on the CMS-1500 claim form. Instructions for completing the UB- 04 claim form are on the Claims Processing page. Inpatient and outpatient hospital services must be submitted on the UB-04 claim form. If the appeal to RIDOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS). A provider may appeal to the RIDOH if they do not meet the recertification criteria. Failure to do so will result in suspension from the program. Providers obtain license renewal through RIDOH and then forward a copy of the renewal documentation to Gainwell Technologies. Gainwell Technologies should receive this information at least five business days prior to the expiration date of the license. Medicaid providers are periodically recertified by RIDOH. Providers must also be qualified to participate under Medicare. Out of state hospitals must be licensed by their state equivalent of the RIDOH and be JCAHO approved. To participate in the Medicaid Program, providers must be licensed by the Rhode Island Department of Health (RIDOH). Hospital Coverage Guidelines Provider Participation Medicaid State Plan Scanned PDF Version.2021 Medicaid Managed Care Member Survey.FPL Guidelines And Eligibility Information.Nursing Home Isolation Unit Supplemental Funding.HCBS Workforce Recruitment and Retention.Home and Community-Based Services (HCBS) Access Program.Early Intervention Provider Relief Program.Children’s Services Provider Relief Program.Children’s Behavioral Health System of Care.Certified Community Behavioral Health Clinics Infrastructure Grant Program.
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