Long Term Care
Table of Contents
Preface Information
- Desk Reference Guide
- Acronyms and Abbreviations
Program Information
- General Program Information
- Program Background and Objectives
- Provider Agreement and Professional Standards
- Payer of Last Resort
- Program Reimbursement
- Payment in Full
- Incorrect Payment
- Claim Submission Timeliness
- Medical and Other Record Content Requirements
- Record Retention Requirements
-
- Provider Participation and Enrollment
- Participation
- Enrollment
- Re-certification
- Suspension or Termination
- Electronic Media Claims (EMC) Enrollment
-
- Program Communication and Services
- Written Correspondence
- Telephone Inquiries
- Provider Training
- On-Site Visits
- Publications
- Direct Deposit
-
- Recipient Eligibility and Identification
- Benefit Levels
- Categorically Needy
- Medically Needy
- Qualified Medicare Beneficiaries (QMBs)
- EPSDT
- Identification Card
- Altered ID Cards and Other Abuses
- Inmates Ineligible for Medical Assistance Program
Benefits
- Recipient Eligibility Verification System (REVS)
-
- Flexible Test of Income
- Spend-Down Liability (SDL)
- Determining Payment When a Spend-Down Amount Is
Applied
-
- Third Party Liability (TPL) for Medical Expenses
- Claims Filing
- Refunds Resulting From Other Insurance
- Co-insurance and Deductible
-
- Services Utilization Review (SURS)
- Review of Services Utilized
-
- RIte Care Program
- Overview
- Participating Health Plans
- Eligibility
- Enrollment
- Copayment and Premiums
- Scope of Services
Claim Management Information
- General Billing Information
- Typed and Handwritten Claims
- Submitting Copies
- Attachments for Claims
- Provider Signature
- Correct Postage
- Using a Billing Company
- Requesting Change of Address/Change of Status
- Non-Providers
- Ordering Claim Forms
- Timeliness Requirements
- Hand-Delivered Paper and Electronic Claims
- Claim Form Order Card
- Provider Manual Order Form
-
- Out-of-State and Emergency Claims
- Medical Services Provided Outside of Rhode Island
- Prior Authorization
- Exceptions to Prior Authorization
- Circumstances In Which Medical Care Is Provided
- Payments
- Timeliness
- Border Communities
-
- Prior Authorization (PA)
- PA Instructions
-
- Claim Correction Form (CCF)
- CCF Instructions
-
- Remittance Advice (RA)
- Banner Page
- Paid, Denied, Claims in Process
- Adjusted Claims
- Financial Items
- TPL and Medicare
- Earnings Data and Error Messages
-
- Paid Claim Adjustments and Refunds
- Single and Multiple Adjustment Request Forms
- Information Required
- Attachments
- Single Adjustment Request Form Instructions
- Multiple Adjustment Request Form Instructions
- Refunds or Recoupments of Paid Claims
- Underpayment
Medical Coverage Policies
Please note that policy and procedures are subject to change. Refer to your
provider update bulletins regarding your provider type.
Claim Billing Guidelines
Covered Services
Limitations/Special Requirements
Non-Covered Services
Out of State Providers
Prospective Reimbursement System
Provider Participation Guidelines
Recertification
Reimbursement Guidelines
Claim Preparation Instructions
- UB-04 Form Filing Instructions
- Long Term Care – UB-04 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 (TPL) Carrier Codes
- Third
Party Liability (TPL) Carrier Codes (PDF Format)
- Third Party Liability (TPL) Coverage Codes
-
For specific questions you may contact the EDS 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.
|
