Durable Medical Equipment

Provider Representative:  Fidelia Williams-Edward Tel. (401) 648-3759
                                               email:fidelia.williams@gainwelltechnologies.com

Provider Reference Manual

Durable Medical Equipment Reference Manual  

Updates

• Prior Authorization for Durable Medical Equipment (DME)
• The Enteral Nutrition Guidelines can be found in the DME Reference Manual

Useful Information

Prior Authorizations for Durable Medical Equipment

For those beneficiaries dually enrolled in the RI Medicaid Program and Medicare, including Medicare part C, prior authorization is not required for Medicare covered DME services. 

Providers are required to accept Medicare assignment for all covered DME services. RI Medicaid will reimburse the copay and/or deductible as determined by Medicare up to the RI maximum allowable amount using the lesser of logic. 

 When prior authorization is required for a service, and the recipient falls into the following categories, then RI Medicaid will require a Prior authorization.

▪ has RI Medicaid as their primary plan

▪ not dually enrolled in Medicare or Medicare part C

has other insurance or Third-party Liability

For DME services denied by Medicare as non-covered but requiring a PA from RI Medicaid, please submit a Medicare EOB with the PA request. 

Prior Authorization requests must be completed by the DME supplier and faxed to 401-784-3892

CPT K1005
Effective 3/1/23, Rhode Island Medicaid Fee-for-Service will be activating coverage for HCPCS code K1005 - Disposable collection and storage bag for breast milk, any size, any type.  Reimbursement is $0.24 per unit with a maximum of 120 units per month. 

No prior authorization is required.  Vendor must verify continued medical necessity for lactating members on a monthly basis prior to delivering refills for this item per DME regulations detailed on page 11 of the DME Provider Manual under Refill Requirements.  This item must be billed monthly.  Three-month and/or automatic shipments are not permitted. 

Home Health Final Rule (2348-F) Effective July 1, 2017 

Below are details of the Home Health Final Rule (2348-F) from CMS, including Medicaid face-to-face requirements for home health services, policy changes, and clarifications related to home health and Durable Medical Equipment.  For more information click the following links:     

•   Medicaid Program: Face-to-Face Requirements for Home Health Services; Policy Changes and      Clarifications Related to Home Health- A Rule by the Centers for Medicare and Medicaid                  Services on 02/02/2016      
• DME Items:  Face to Face Requirement Effective 7/1/2017   

Durable Medical Equipment Reimbursement Effective July 1, 2012

The Rhode Island Executive Office of Health and Human Services, in conjunction with the State Fiscal Year 2013 Budget, have been directed to implement a new reimbursement rate for durable medical equipment.  The new rate is 85% of the Medicare Fee Schedule and will be effective retroactively to 7/1/2012.  Adjustments will take place during each of the five financial cycles of May through June 2013.  Should you have questions, please contact Customer Service at 401-784-8100 for local and long distance calls or 1-800-962-6411 for in-state toll calls and border communities.

Financial Cycle Date Months To Be Adjusted

 May 10, 2013July and August 2012 

 May 17, 2013September and October 2012

May 31, 2013November and December 2012

June 14, 2013January and February 2013

June 28, 2013March and April 2013