Medicaid Managed Care Manual

1.0 Introduction 2023

2.1 340B Policies and Procedures_2023

2.2 Childhood Lead Poisoning Prevention Program Referral Intervention Process_2023

2.3 EPSDT Periodicity Schedule_2023

2.4 Pharmacy Benefit Plan Protocols_2023 (01/01/2026)

2.5 RI Nutrition Standards_2023

2.6 Schedule of In Plan Oral Health Benefits

2.7 Extended Family Planning Services_2023

2.8 Treatment of Hepatitis C Prior Authorization Guidelines

2.9 Mental Health, Substance Use and Developmental Disability Services for Children 05-26-21_2023

2.10 Behavioral Health and Substance Use Services for Adults (01/01/2026)

2.11 Policies and Procedures In Lieu of Services (01/01/2026)

2.12 Policies and Procedures Value-Added Services (01/01/2026)       

3.1 RI EOHHS Guidelines for Marketing and Member Communications for Medicaid Managed Care Program 

3.2 Attachment A - Non-Discrimination Notice

3.3 Attachment B - Marketing & Member Communications Request for Approval 

3.4 Attachment C - Notice of RI EOHHS Approval, Conditional Approval, or Rejection of Marketing & Member Communications Request for Approval 

4.1 Rhode Island Medicaid Managed Care Encounter Data Quality Measurement (08/2021)

4.2 EOHHS 837 Companion Guide 1 of 2

4.3 EOHHS 837 Companion Guide 2 of 2

4.4 OTP HH Medicaid Billing Manual (02/2017)

4.5 IHH and ACT Program Billing Manual for RI (DRAFT)

Financial documentation will be provided upon readiness.

 

5.1 Managed Care Health Plan Financial Reporting Program

5.2 APM Requirements for Managed Care Manual

6.1 Providers RI Model Member Handbook Model FINAL

6.2 VendorAddressChange_REPORTDATARANGE_HEALTHPLAN_V1.2

To be Developed

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9.1 Quality Assessment and Performance Improvement

9.2 RI Medicaid Managed Care Quality Strategy (08-2022)

9.3 Rhode Island Medicaid Managed Care Encounter Data Quality Measurement

10.1 Providers Appeal Grievance Rights Template (09/2021)

EOHHS Medicaid Managed Care Reporting Templates

11.1 Reports of Legal and Other Proceedings

11.2 EOHHS Core Contract Requirements for Reporting and Intermediate Sanctions 2020 Policy (6/2024)

11.3 Attestation Statement for Health Plan Reporting Submission (11/2024)

11.4 Medicaid Managed Care Report Date Change Request Form (10/2018)

11.5 DRAFT - CY24_MCO_Core_Contract_Reporting_Calendar (11/2023)

EOHHS Medicaid Managed Care Reporting Templates

11.6 AE Quality Measure QPY4

11.7 Clinical Data Exchange Implementation Status

11.8 MCO AE Milestone Performance Report (PY3)

11.9 MCO AE Milestone Performance Report (PY4)

11.10 AEIP Quarterly Outcome Metrics OPY4

11.11 AEIP Annual Outcome Metrics

11.12 TCOC Performance Report

11.13 Final TCOC Performance

11.14 AE Base Contract Checklist

11.15 Final ROI Project

11.16 APM Report

11.17 Access Report

11.18 Care Management

11.19 Claims Timely Filing Processing

11.20 QIP

11.21 Appeals

11.22 MCO Call Center Metrics

11.23 Grievance Complaints

11.24 MCO Program Integrity

11.25 Member Fraud Out of State

11.26 MCFU Case Presentation Report

11.27 837 Processing

11.28 Newborn File

11.29 Vendor Address Change

11.30 COVID Vaccine Non-Risk Base Payment

11.31 Immunization Tracker

11.32 Provider Termination and Network Change

11.33 Member Transition Plan

AE Attribution Technical Requirements

11.34 AE Attribution Technical Requirement V2.0

11.35 AE Attribution Technical Appendix NHPRI V2.0

11.36 AE Attribution Technical Appendix UHC V2.0

AE Provider Roster Technical Requirements

11.37 AE Provider Roster Specifications Technical Requirements 2.0

11.38 AE Provider Roster Technical Appendix UHC V2.0

11.39 AE Provider Roster Technical Appendix NHP V2.0

Medicaid Managed Care Policies and Guidelines

13.1 EOHHS MCO Core Contract Requirements for Reporting Demographic Changes 2020 Policy V1.5

13.2 EOHHS Provider Termination and Network Changes 2020 Policy V1.3

13.3 Immunization Tracker Guidelines for Health Plans

 

Medicaid Health Plan Change Request Form

13.4a Medicaid Health Plan Change Request Form - English (05/2024)

13.4b Medicaid Health Plan Change Request Form - Portuguese (05/2024)

13.4c Medicaid Health Plan Change Request Form - Spanish (05/2024)