Hospitals

Inpatient Facility

Outpatient Facility

Provider Representative

Care New England and Out of State Facilities:
 

Karen Murphy   Tel. (571) 348-5933

email: karen.murphy3@gainwelltechnologies.com

Provider Representative

Independent Facilities:
Andrea Rohrer   Tel.(469) 897-4389

email: andrea.rohrer@gainwelltechnologies.com     

Provider Representative

Lifespan Facilities: 
Fidelia Williams-Edward   Tel. (401)648-3759

email:  fidelia.williams@gainwelltechnologies.com                                                                                            

Prior Authorization

Prior Authorization is not required if Medicaid is the second payer.

Inpatient Hospital stays are authorized by IPRO.  Please contact IPRO at 1-800-357-8417.

Out of State Hospital requests for inpatient or outpatient services require completion of a Prior Authorization request form and supporting clinical documentation.

Non-urgent requests should be mailed to:  Gainwell Technologies

P. O. Box 2010

Warwick, RI  02887-2010

Urgent only requests for both adults and children should be securely emailed to the following EOHHS staff:

Heather Kinsey at heather.kinsey@ohhs.ri.gov



Providers are encouraged to securely email urgent requests if at all possible.  Requests that cannot be securely emailed should be faxed to:

Attn:  Heather Kinsey at (401) 462-6336



For questions, contact Heather Kinsey at (401) 462-1796

 

Reference Guide

See the Institution for Mental Disease (IMD) Assessment Form  pertaining to RI Medicaid Program Institutions for Mental Diseases  210-RICR-10-00-7  (4/8/2020).

Updates

Effective with admission date July 1, 2010, Rhode Island Medicaid will be implementing All Patient Refined Diagnosis Related Groups (APR-DRGs) for pricing of inpatient claims. For additional information, please see:

Frequently Asked Questions  

RI DRG Calculator July 1, 2023

RI DRG Calculator July 1, 2022

RI DRG Calculator July 1, 2021

RI DRG Calculator July 1, 2020 

RI DRG Calculator July 1, 2019 

RI DRG Calculator July 1, 2018   

RI DRG Calculator October 1, 2017  

RI DRG Calculator July 1, 2016  

RI DRG Calculator December 1, 2015

RI DRG Calculator July 1, 2012 

RI DRG Calculator July 1, 2011 

RI RRG Calculator July 1, 2010 

Effective October 1, 2009, Outpatient Hospital Facility claims with dates of service October 1, 2009 or greater will be subject to the new Ambulatory Payment Classification (APC) Fee Schedule.  For more additional information, please see:

DHS notification letter 

APC Fee Schedule 2023 Updated October 2023

APC Fee Schedule 2022  

APC Fee Schedule 2021

APC Fee Schedule 2020  

APC Fee Schedule  2019  

APC Status Codes Updated October 2023

Frequently Asked Questions 

Laboratory Procedure Codes  December 2023

Radiology Procedure Codes  December 2023

CMS added six new APC status indicators to the list that will need to be incorporated into the current APC pricing logic. 

This new payment methodology requires a new “conditionally packaged” logic that checks the APC status indicator of the other HCPCS on the claim to see if any of the conditions are met.  The below table will describe the CMS guidelines of this conditional packaging.

An updated APC Status Code list can be found on the EOHHS website Fee Schedule page.

APC Status Code

APC STAUS DESCRIPTION

PRICING (Logic)

D

Discontinued Codes

Reimbursed at zero

E1

Codes/services not covered under outpatient, statutorily excluded or not reasonable/necessary

Reimbursed at zero

E2

Codes/services for which pricing info and claims data is not available

Reimbursed at zero

J1

Hospital Part B services paid through a comprehensive APC

Reimbursed at APC fee schedule for costliest J1 on the claim.  Other HCPCS on the claim with APC action codes N, Q1, Q2, P, S, V, and lower cost J1, K and R are reimbursed at zero.

J2

Hospital Part B services that may be paid through a comprehensive APC

Reimbursed at APC fee schedule except when included on a claim with a paid J1 APC Status Indicator, in which case reimbursed at zero

Q4

Conditionally Packaged Laboratory Tests

Reimbursed at zero if claim also has a procedure code with an APC status indicator of J1, J2, S, V, Q1, Q2, or Q3.  Otherwise reimbursed using lab or therapy fee schedules, as applicable.

J Codes Requiring NDC

J Code Conversion Table  Updated January 2024

Eleanor Slater Hospital

Please visit the Department of Behavioral Health, Developmental Disabilities, and Hospitals (BHDDH) CMS Price Transparency Website for Eleanor Slater Hospital rate setting information.

Government-Owned and -Operated Hospital Billing Manual