Inpatient Facility
Outpatient Facility

Provider Representative
Care New England and Out of State Facilities: 
Karen Murphy   Tel. (571) 348-5933

Provider Representative
Independent Facilities: Andrea Rohrer   Tel.(469) 897-4389

Provider Representative
Lifespan Facilities:  Fidelia Williams-Edward   Tel. (401)648-3759

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

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).


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:

Frequently Asked Questions  

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 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.

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 May 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.

Government-Owned and -Operated Hospital Billing Manual