Hospital Coverage Guidelines

Provider Participation

To participate in the Medicaid Program, providers must be licensed by the Rhode Island Department of Health (RIDOH). Out of state hospitals must be licensed by their state equivalent of the RIDOH and be JCAHO approved. Providers must also be qualified to participate under Medicare.


Medicaid providers are periodically recertified by RIDOH. Providers obtain license renewal through RIDOH and then forward a copy of the renewal documentation to Gainwell Technologies. Gainwell Technologies should receive this information at least five business days prior to the expiration date of the license. Failure to do so will result in suspension from the program. A provider may appeal to the RIDOH if they do not meet the recertification criteria. If the appeal to RIDOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS).

Claim Billing Guidelines

Inpatient and outpatient hospital services must be submitted on the UB-04 claim form. Instructions for completing the UB- 04 claim form are on the Claims Processing page.

Professional services provided by hospital-based physicians must be billed on the CMS-1500 claim form. Refer to the Provider Enrollment page for enrollment information.

UB-04 claim forms are submitted with a combination of Revenue Coding codes, International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) diagnosis codes (version based on date(s) of service) and, in certain circumstances, Current Procedure Terminology (CPT), HCFA and Common Procedural Coding System (HCPCS). See Definition Section below for description of these coding structures.

Appropriate usage of CPT, HCPCS and ICD-9/ICD-10 codes is imperative. The Rhode Island Medicaid program adheres to all code descriptions and limitations regarding age, sex, time, inclusive services and all other guidelines as outlined in the CPT, HCPCS and ICD-9/ICD-10 code books. Incorrect or incomplete billing of these codes may result in denial or recoupment of reimbursement.

Out-of-state hospital providers must follow the same coding guidelines as in-state providers.

Definition of terms:

Medical Necessity means the medical, surgical or other health services for diagnosis, cure, or treatment, including preventing deterioration of the involved physical or mental condition. Such services must be provided in the most cost effective and appropriate setting and shall not be provided solely for the convenience of the recipient or the service provider.

Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.

HCFA Common Procedure Coding System (HCPCS) is a coding system developed by the Health Care Financing Administration to provide a common system for referencing health care procedures performed under the Medicare and Medicaid programs.

International Classification of Disease, 9th Revision (ICD-9)/10th Revision (ICD-10)  is an index of diseases and diagnostic terms to report illnesses, injuries, and reason for encounter with health care providers. Coding version is determined by date(s) of service.

Prior authorization (PA) is authorization for a procedure or course of treatment obtained before services are rendered.

Reimbursement Guidelines

Providers must bill the Medicaid Program at the same usual and customary rate as charged to the general public. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to Medicaid. Payments to providers will not exceed the maximum reimbursement rate of the Medicaid Program.

Out of State Providers

Prior Authorizations are required for services rendered out of state for RI Medicaid beneficiaries per RI Code of Regulations, 210-RICR-20-00-3, Chapter 20-Medicaid Payments and Provider.

3.3 Requirement of Prior Authorization

  A.  Payment for out-of-state medical services that are provided to eligible Medicaid beneficiaries living within Rhode Island requires prior authorization from the Executive Office of Health and Human Services (EOHHS).

  B.  The following conditions must be met to obtain prior authorization for out-of-state medical services:

1.  If a Medicaid beneficiary requires services from an out-of-state hospital or physician, the  beneficiary's attending physician must submit written justification to EOHHS;

2.  The medical services that are required and being requested must not be available within Rhode Island.

  C.  Out-of-state medical service require prior authorization.  Only those services that are contained within the Rhode Island Medicaid scope of services will be reimbursed.

3.4 Exceptions to the Requirements for Prior Authorization

  A.  The following provisions are exceptions to the requirement for prior authorization:

1.  Emergency medical treatment and hospital services needed because the beneficiary's health would be endangered if travel back to Rhode Island was required;

2.  Treatment was provided by hospitals and practitioners located in one of the border communities where it is the general practice for residents to use the medical resources in these communities;

3.  Medical and hospital treatment provided to foster children residing with families outside Rhode Island or in out-of state residential treatment centers.

Prior Authorization Instructions and Forms can be found Prior Authorization Forms.

For further questions, please contact the Out-of-State Provider Representative, Karen Murphy at (401)784-8004 or via email at

Out of State Hospital requests for inpatient or outpatient services require completion of a Prior Authorization request form and supporting clinical documentation.  If the beneficiary has other primary insurance and Medicaid is secondary, no prior authorization is required.

Non-urgent requests should be mailed to:  Gainwell Technologies

                                                                              PO 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

Authorized inpatient hospital services shall be reimbursed using All Patient Refined -Diagnosis Related Grouping (APR-DRG).

Authorized outpatient services (other than laboratory services) shall be reimbursed using Ambulatory Payment Classifications (APCs).

Federally Regulated Services

Sterilization, hysterectomy and abortion procedures require that specific documentation be obtained from the recipients receiving these services. This documentation requirement is the responsibility of the provider of service and must be attached to the claim in order to receive reimbursement for the service. Failure to appropriately complete these forms may result in denial of the claim.

Medicare/Medicaid Crossovers

Medicaid will pay the Medicare coinsurance and deductible times the ratio of cost to charges (RCC).