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 May 18, 2023, Equality in Abortion Coverage Act was signed into law by the State of Rhode Island.
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:
RI DRG Calculator July 1, 2024
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 2024 Updated August 2024
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 April 2024
Radiology Procedure Codes April 2024
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 November 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.