Prior Authorization

Medicaid is required to ensure that providers and members alike are fully informed of the prior authorization process and time frames. Rhode Island requires prior authorization for certain medical procedures and services.

Instructions for Providers

Complete the Prior Authorization Form (below) and fax or mail it to Gainwell Technologies (see address below). Be sure to include supporting documentation for review.

• Prior Authorization Form
• Prior Authorization Instructions 

There can be multiple line items on a Prior Authorization Form but only one procedural code (PROC) or revenue code (REV) per line.

Completed forms can be faxed or mailed to:

• Fax Number:  401-784-3892 (up to a maximum of 15 pages)
• Mailing address: Gainwell Technologies- Prior Authorization, P.O. Box 2010, Warwick, RI 02887-2010

Certain programs have specific guidelines and forms to obtain prior authorization. See the links below for more information on these programs or services:

• Biomarker Testing
• Durable Medical Equipment (DME)
• Hospital
• Pharmacy
• Radiology Prior Authorization

Please review the Medicaid Provider Manual for additional covered benefits that may require a Prior Authorization.

Timing and Status

The State will respond to standard prior authorization requests within 7 days of their submission. Expedited or urgent requests will be responded to within 72 hours. A prior authorization can be:

• Approved- meaning the request is authorized
• Modified-meaning the request is authorized, however the services or item may not be in the exact quantity or nature in which originally requested
• Denied-meaning the request is not authorized and Rhode Island Medicaid will not pay for the service. If the request is denied, Medicaid will provide specific reasons that explain the medical rationale for the denial of the request.   
• Deferred-meaning the request is returned to the provider and/or beneficiary for additional information before a decision can be made

Provider Support

The Medicaid Customer Service Help Desk is available Monday-Friday from 8 a.m. to 5 p.m. The local and long-distance number is (401) 784-8100 and the in-state toll call and border community number is 1-800-964-6211.  

For more information, please find your provider representative.