RI Medicaid Program HIPAA 5010

January 1, 2012 was the compliance date for the 5010 transactions. This final rule mandates adoption of newer versions of the original HIPAA standard transactions.

Rhode Island is now compliant with CMS requirements for the 5010 & NCPDP D.O standards. As of February 18th, 2012, we no longer accept 4010 transactions. At this time, we are only accepting the 5010 format for the following transaction sets:

837P, I and D – Professional, Institutional and Dental

270 and 271 – Eligibility Inquiry and Response

277U – Unsolicited – Health care claim status

835 – Health care payment and remittance advice

NCPDP D.O. – POS Retail Pharmacy Drug and Professional Services

If you are a Provider Electronic Solutions software user (PES) you should be using the most current version.  The newest version can be found on the Provider Electronic Solutions web page.

 If you need any assistance upgrading to the current version, please contact our EDI Coordinator Mary Jane Nardone at 401-784-8014 or mary-jane.nardone@gainwelltechnologies.com.

RI Medicaid HIPAA Companion Guide

The RI Medicaid Companion Guide includes the technical specifications for the:

  • 837 version 5010 for institutional, professional and dental electronic claims
  • 999 functional acknowledgement
  • 277 unsolicited claim response
  • 835 electronic remittance 
  • 270/271 Eligibility Request/Response

These specifications are to be used in conjunction with the National Electronic Data Interchange Transaction Set Implementation Guides to provide supplemental information specific to RI Medicaid as permitted within the structures of the HIPAA transaction sets.

Information pertaining to the Gainwell Technologies translator, interface specifications, the Trading Partner Agreement, Provider Services contacts, and HIPAA resources are also contained in this document.

Other Resources

For additional information visit RI Health Insurance Portability & Accountability Act (HIPAA)