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

All Medicaid claims must be received within 365 days of the first date of service in order to be accepted for processing and payment.
If the client has other insurance and the claim is past the 365 day limit then an exception will be allowed to process the claim if the other insurance EOB is within the past 90 days.  The claim and supporting documentation to prove timely filing must be submitted on the appropriate paper claim form to your Provider Representative.

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)  
EOB Codes and Messages (Spanish)

Program Information

Provider Manuals and Guidelines