Provider News

Electronic Secondary  Billing for Medicare and Senior Replacement Plans
Please view billing instructions if using the Provider Electronic Solutions Software.  The appropriate Carrier Codes can be found in the table below.

Electronic Secondary Billing for Medicare and Senior Replacement Plans
To facilitate electronic billing and proper reimbursement for Medicare and Commercial Medicare Plans (Advantage/Replacement Plans) such as United Senior Care, Blue-Chip Medicare HMO, WellCare Advantage Plan the following fields are required:

  • Loop 2320 Other Subscriber Information SBR09 - Must contain MA or MB as appropriate for the claim filing indictor
  • Loop 2320 Claim Level Adjustments CAS segment - Must contain Deductible PR 1 or Coinsurance of PR 2
  • Loop 2320 Coordination of Benefits (COB) Payer Paid Amount – Must contain the Amount Paid (other insurance paid amount)
  • Loop 2330B Other Payer Name (Carrier Code) Segment NM109 Other Payer Primary Identifier – Must contain the appropriate carrier code, see below for a list:

MDA/MDB – Medicare

22A – Aetna Medicare Advantage Plan

06A – United Senior Care

24A – Connecticare Medicare Advantage Plan

08A – Healthfirst Medicare Advantage Plan

26A – Humana Medicare Advantage Plan

09A – HMO Blue of Massachusetts Advantage Plan

26B – Humana Medicare Advantage Dental Plan

12A – Blue Chip Medicare HMO

89A – Tufts Health Plan (PPO) Medicare Advantage Plan

18A – Wellcare Medicare Advantage Plan

C01 – CarePlus Advantage Plan

19A – MMM Healthcare of Puerto Rico Advantage Plan

C02 – Commonwealth Care Alliance, Inc. Medicare Advantage Plan

Outpatient Hospitals

The Outpatient Prospective Payment System (OPPS) is a pricing methodology used by Medicare to price Outpatient Hospital claims.  This methodology groups Healthcare Common Procedure Coding System (HCPCS), or procedure codes, to an Ambulatory Payment Classification (APC) status indicator/action code based on clinical and cost similarities.  The assignment of HCPCS to APC status indicator is determined by CMS.  Recently, CMS has 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




Discontinued Codes

Reimbursed at zero


Codes/services not covered under outpatient, statutorily excluded or not reasonable/necessary

Reimbursed at zero


Codes/services for which pricing info and claims data is not available

Reimbursed at zero


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.


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


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.


Durable Medical Equipment Providers

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. 


Attention Assisted Living Facilities (ALF) Providers

Effective January 1, 2023, the monthly Room and Board Rate for all Medicaid LTSS Assisted Living customers will change to $1,246.00 to reflect the Year 2023 Federal Benefit Rate (FBR).  Cost of Care (COC) may also change to reflect the 2023 COLA for customers who are receiving SSA benefits.  For customers with income below $1,246.00, their R&B may be less. 

For assistance, questions, or concerns, please contact:

LTSS Coverage: 401-574-8474 or DHS Coverage: 1-855-697-4347 or the LTSS Email: . 

For Cost of Care (COC) and Room and Board updates and discrepancies, please contact:

OHHS Contacts:   or 



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