Claims Processing
Electronic Claims
Providers who want to submit claims electronically - whether through a clearinghouse, with software obtained from an approved vendor, or through Provider Electronic Solutions software - must complete an online Trading Partner Agreement Application in the Healthcare Portal. All electronic transactions must be HIPAA compliant.
Provider Electronic Solutions software is available for RI Medicaid Providers. Download a copy of the software and try it for free- Provider Electronic Solutions. Gainwell Technologies Provider Representatives will assist you and get you started. For more information, please contact your Provider Representative.
Paper Claim - Forms and Instructions
Submission of paper claims is available for those claims that require attachments (i.e. invoice documentation for DME supplies, if required). All paper claims and documentation should be mailed to:
Gainwell Technologies
PO Box 2010
Warwick, RI 02887-2010
Reminder: CMS 1500 Version 02/12 is required after April 1, 2014, regardless of date of service.
CMS-1500 Claim Form Instructions
UB-04 Claim Form Instructions
Dental Claim Form Instructions
Waiver Claim Form Instructions
NDC Attachment Form Instructions
Time Limits for Filing Claims
A claim for services provided to a Medicaid client, with no other health insurance, has to be received by the States’ fiscal agent, Gainwell Technologies within 365 days of the date of service. If the claim is over a year old then a list of the criteria to bypass timely filing is as follows:
• Retroactive client eligibility (within the previous 90 days)
• Retroactive provider enrollment (within the previous 90 days)
• Previous denial from Medicaid (other than a timely filing denial) within the previous 90 days
• Gainwell Technologies processing error within the previous 90 days
• Recoupment of a claim within the previous 90 days. Please note that a recoupment of claims greater than 365 days are not allowed when a new claim will be submitted for increased reimbursement, unless there is a primary payer EOB dated within 90 days.
• Adjustments to a paid claim, over a year old, will be accepted up to 90 days from the remittance advice date that the original claim payment was posted. Adjustments for claims over one year old, cannot be adjusted to pay at a higher amount than originally paid.
• Prior Authorization or TPL updates within 90 days.
Claims with a date of service over one year that meet any of the above criteria must be submitted within ninety (90) days from the remittance advice date and/or PA or TPL update. Any claim appeal that does not meet these criteria will be denied for timely filing.
Claims with a date of service over one year with an involved third-party payer (insurance) must be submitted within ninety (90) days of the payer’s valid Explanation of Benefits (EOB) date. Denials for timely filing or failure to comply with the primary payer rules are not included in this exception.
Any claim with a service date over one year and an EOB date from another payer over 90 days will be denied for timely filing. Claims over 1 year old that meet the timely filing criteria must be sent to the Provider Representative for handling.
Claims Payment
The RI Medicaid Program no longer issues paper checks for claims payment. All payments will be made electronically by automatic deposit into the account specified on the Provider's Electronic Funds Transfer form.
To initiate the automatic deposit process, providers must complete and return the EFT Authorization Form and attach a voided check to confirm the provider's account number and bank transit number.
Claims Processing and Payment Schedule - Claims are processed for payment approximately every two weeks.
Claim Status
To check on the status of a claim:
- Providers can check claim status on the Healthcare Portal (Please see the Healthcare Portal page for information on how to register or use the site); or
- By calling the RI Medicaid Customer Service Help Desk at 401-784-8100 for local and long distance calls or 1-800-964-6211 for in-state toll call and border communities.
Claim Adjustment Forms and Other Related Forms
Claim adjustments can only be performed on Paid Claims. A copy of the the Remittance Advice page is required with the Adjustment Form in order for processing.
Adjustment Form Adjustment Form Instructions
Recoupment Form Recoupment Form Instructions
Refund Log
Third Party Liability
Procedural Information
Recipient Eligibility
Use the Healthcare Portal (Please see the Healthcare Portal page for information on how to register or use the site) or call the Customer Service Help Desk to find out if a recipient is eligible for Medicaid.
Prior Authorization
For information on how to obtain Prior Authorization.
Third Party Liability (TPL) Carrier Codes
The 3 digit carrier is required for claim with a primary insurance. Refer to Third Party Liability for the appropriate code.
Attending
Frequently Asked Questions for Attending Providers
Order, Prescribe, and Refer (OPR)
Frequently Asked Questions for OPR
CPT Codes/HCPCS Codes
To find the reimbursement amount for a CPT or HCPCS code, go to Fee Schedules.
Electronic Billing for Medicare and Senior Replacement/Advantage Plans
Electronic Billing for Medicare and Senior Replacement/Advantage Plans
Error Status Codes
ESC Code List (English)
Explanation of Benefits (EOB) Codes
EOB Codes and Messages (English)
Program Information