Physician

Medical Coverage Guidelines

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

• Physician Coverage Guidelines
  • Allergy Testing and Desensitization
  • Anesthesia Services
  • Biomarker Testing
  • Cardiology
  • Claims Billing Guidelines
  • Co-payment
  • Covered/ Non-covered Services
  • Definitions
  • Dialysis
  • EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)
  • Evaluation and Management (E&M)
  • Injections
  • Laboratory and Pathology
  • Limitations/ Special Requirements
  • Managed Care
  • Maternity Care and Delivery
  • Medicare/Medicaid
  • Ophthalmology
  • Physician Assistants
  • Pre-Certification
  • Provider Participation
  • Radiology Services
  • Recertification
  • Reimbursement Guidelines
  • Surgery
• Prior Approval Criteria for Surgical Procedures
  • Augmentation Mammoplasty
  • Bariatric Surgery
  • Blepharoplasty
  • Breast Reconstruction
  • Dermabrasion
  • Gender Dysphoria
  • Panniculectomy/Abdominoplasty
  • Reduction Mammoplasty
  • Rhinoplasty and Septorhinoplasty
• Services Requiring Adherence To Federal Guidelines
  • Abortion Review Guidelines
  • Hysterectomy Acknowledge Consent Form
  • Sterilization Procedures
  • Consent Form
  • Verification Guidelines For Sterilization Consent Forms

Prior Authorization for Durable Medical Equipment (DME)

Physicians writing scripts/prescriptions for durable medical equipment (i.e. diapers, nutrition, etc.) should give the script directly to the recipient and indicate to the recipient to contact a DME Supplier provider.  The DME Supplier provider will initiate the prior authorization request with RI Medicaid. 

When prior authorization is required for a service, the DME Supplier provider is to submit a completed Prior Authorization Request form which can be obtained on the Prior Authorization page. This form must be signed and dated by the DME Supplier provider as to the accuracy of the service requested. Attached to this form will be the Proof of Medical Necessity signed by the prescribing provider. When necessary, further documentation should be attached to the Prior Authorization Request form to justify the request.  Forms can be faxed to (401) 784-3892. 

Please note prior authorization requests for DME supplies received from a physician will be returned.

Prior authorization does not guarantee payment. Payment is subject to all general conditions of RI Medicaid, including beneficiary eligibility, other insurance, and program restrictions.

An approved prior authorization cannot be transferred from one vendor to another. If the beneficiary wishes to change vendors once the prior authorization has been approved, the new vendor will submit another Prior Authorization Request form with a letter from the beneficiary requesting the previous prior authorization be canceled.

For those beneficiary’s dually enrolled in the RI Medicaid Program and Medicare, prior authorization is not required for Medicare covered DME services. Providers are required to accept Medicare assignment for all covered DME services. RI Medicaid will reimburse the copay and/or deductible as determined by Medicare up to the RI maximum allowable amount using the lesser of logic.

Claim Preparation Instructions

• CMS 1500 Form Filing Instructions 
• Physician Services - CMS 1500 Claim Form  

Error Status Codes

• ESC Code List (English) 

Explanation of Benefits (EOB) Codes

• EOB Codes and Messags 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.