Physician

Medical Coverage Guidelines

Please note that coverage guidelines and procedures are subject to change. Refer to the monthly Provider Update for more information.

• Physician Coverage Guidelines
  
  • Allergy Testing and Desensitization
  • Anesthesia Services
  • Cardiology
  • Claims Billing Guidelines
  • Co-payment
  • Covered/ Non-covered Services
  • Definitions
  • Dialysis
  • EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)
  • Evaluation and Management (E&M)
  • Injections
  • Laboratory and Pathology
  • Limitations/ Special Requirements
  • Managed Care
  • Maternity Care and Delivery
  • Medicare/Medicaid
  • Ophthalmology
  • Physician Assistants
  • Pre-Certification
  • Provider Participation
  • Radiology Services
  • Recertification
  • Reimbursement Guidelines
  • Surgery
• Prior Approval Criteria for Surgical Procedures
  • Augmentation Mammoplasty
  • Bariatric Surgery
  • Blepharoplasty
  • Breast Reconstruction
  • Dermabrasion
  • Gender Dysphoria
  • Panniculectomy/Abdominoplasty
  • Reduction Mammoplasty
  • Rhinoplasty and Septorhinoplasty
• Services Requiring Adherence To Federal Guidelines
  • Abortion Review Guidelines
  • Hysterectomy Acknowledge Consent Form
  • Sterilization Procedures
  • Consent Form
  • Verification Guidelines For Sterilization Consent Forms

Claim Preparation Instructions

• CMS 1500 Form Filing Instructions 
• Physician Services - CMS 1500 Claim Form  

Error Status Codes

• ESC Code List (English) 

Explanation of Benefits (EOB) Codes

• EOB Codes and Messags List (English) 
• EOB Codes and Messages List (Spanish) 

Appendix - Third Party Liability Carrier and Coverage Codes

• Third Party Liability (TPL) Carrier Codes 
• Third Party Liability (TPL) Coverage Codes
  
  
For specific questions you may contact the Customer Service Help Desk at (401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll callers and border communities.