Home And Community Based Services

Medical Coverage Guidelines

Please note that coverage guidelines and procedures are subject to change. Refer to the monthly Provider Update for more information.

Home and Community Based Services Provider Reference Manual

Federal Rule

Home Care Services Rates (effective 7/1/2019)  

Updates

LTSS Providers

Effective 9/13/22 you will notice that two of the waiver/program names have changed in the Healthcare Portal when you are checking for member eligibility.  The member is still eligible for the same services that they were eligible for under their prior waiver/program name.  Please note that only the names of the programs have changed.   

Core Community Services has changed to “LTSS – HCBS Services”

DEA Community Services has changed to “OHA Community Services”

Additionally, recipients can now simultaneously be enrolled in the LTSS-HCBS (formerly core) and one of the following waiver programs:

OHA community waiver program

Shared Living

Habilitation Community Service

Habilitation Group Home Service

Claim Preparation Instructions

Waiver Form Filing Instructions 
Waiver Services - Waiver/Rehab Claim Form 

CMS 1500 Form Filing Instructions 
Waiver Services - CMS 1500 Claim Form 

Error Status Codes

ESC Code List (English) 

Explanation of Benefits (EOB) Codes

EOB Codes and Messages List (English) 
EOB Codes and Messages List (Spanish)

Appendix - Third Party Liability Carrier and Coverage Codes

Third Party Liability Carrier and Coverage Codes

For specific questions you may contact the Customer Service Help Desk at (401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll callers and border communities.

Assisted Living

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

email: fidelia.williams@gainwelltechnologies.com

Reference Guide

Updates

• Billing Updates June 2024
• Effective January 1, 2023, the monthly Room and Board Rate for all Medicaid LTSS Assisted Living customers will change to $1246 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 $1246, 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: dhs.ltss@dhs.ri.gov
  
  For Cost of Care (COC) and Room and Board updates and discrepancies, please contact:
  OHHS Email Contacts:  LTSS Escalation or Sally McGrath
   

• New Explanation of Benefit (EOB) Codes
  Beginning in the remittance advice 10/28/2022, provides will see three new Explanation of Benefit (EOB) codes post to their paid claims:
  
  EOB 1003 – Claim used Tier A
  EOB 1004 – Claim used Tier B
  EOB 1005 – Claim used Tier C
  
  These EOB’s will post to the notify the provider which tier was used to determine the per diem rate for pricing the claim. Additionally, there will be two new Error Status Codes (ESC) aka Edits:
  
  Edit 150 – Provider assisted living level not on file - Claim will suspend with this ESC when the provider’s tier level is not on the provider’s profile.
  Edit 151 – Recipient assisted living level not on file - Claim will suspend with this ESC when the recipient’s tier level is not on file. Recipient tier’s can be verified on the Healthcare Portal.
  
  The 2 edits above will deny with EOB 249 – No rate on file for date of service billed.
  
  For questions, please contact Provider Representative: Fidelia Williams-Edward at fidelia.williams@gainwelltechnologies.com or (401) 648-3759.

   

• Billing Split Tiers and Patient Share
  If a recipient changes their tier level during the month, the charges will need to be billed as 2 separate claims. This is different from past billing procedures.
  
  For example:
  Recipient has Tier A from 11/1/2022 – 11/15/2022 and Tier B from 11/16/2022-11/30/2022.
  This would require 2 claims split to match the dates of service and units/days in each tier.
  
  Additionally, it is important to check patient share on the Healthcare Portal to ensure that the share is entered to match the split in the tier level. If the share is not split and you bill two (2) claims for the month the share will be decremented twice.
  
  If you do not see the patient share split, you will need to contact Fidelia Williams-Edward of Gainwell Technologies at fidelia.williams@gainwelltechnologies.com or (401) 648-3759.