Attention RI Medicaid Members: Update on Prescription Access Due to a cybersecurity issue, a contractor serving pharmacies and Medicaid programs across the US is unable to provide important online services at this time. In Rhode Island, this situation impacted pharmacies’ ability to fill prescriptions for members of the AIDS Drug Assistance Program (ADAP) and the Medicaid Program. In response, RI EOHHS has quickly brought online a new way for pharmacies to process claims. Rhode Island Medicaid has also told pharmacies that they can provide a 30-day supply of any prescriptions you are trying to fill, to help you get through this time. The pharmacy should not charge you for any prescription that is covered by Medicaid. Learn more.
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