Hospital

Coverage Guidelines

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

• Hospital Coverage Guidelines
  • Provider Participation
  • Recertification
  • Claim Billing Guidelines
  • Reimbursement Guidelines
  • Out of State Providers
  • Federally Regulated Services
  • Medicare/Medicaid Crossovers
• Inpatient Services
  • Introduction
  • Reimbursement Guidelines
  • Co-Payment
  • Other Institutions
  • Covered Services
  • 24 Hours Minimum Inpatient Stay
  • Day of Admission
  • Non-covered Services
  • Limitations/ Special Requirements
  • Review Services
  • General Information
  • Pre-Admission Review
  • Length of Stay (LOS) Extension Review
  • Concurrent Reviews
  • Retrospective Review
  • Claims Billing Guidelines
• Outpatient Services
  • Introduction
  • Reimbursement Guidelines
  • Laboratory Services
  • Surgical Services
  • Dialysis
  • Professional Services
  • Multiple Surgical Procedures
  • Emergency Room Co-Payment
  • Covered Services
  • Non-covered Services
  • Limitations/ Special Requirements
  • Claims Billing Guidelines
  • Other Institutions
• Revenue Codes

Claim Preparation Instructions

• UB-04 Form Filing Instructions   
• Inpatient/Outpatient - UB-04 Claim Form 
• CMS 1500 Form Filing Instructions 
• Outpatient Hospital 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.