Physician 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
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- Provider Participation and Enrollment
- Participation
- Enrollment
- Re-certification
- Suspension or Termination
- Electronic Media Claims (EMC) Enrollment
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- Program Communication and Services
- Written Correspondence
- Telephone Inquiries
- Provider Training
- On-Site Visits
- Publications
- Direct Deposit
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- 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)
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- Flexible Test of Income
- Spend-Down Liability (SDL)
- Determining Payment When a Spend-Down Amount Is
Applied
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- Third Party Liability (TPL) for Medical Expenses
- Claims Filing
- Refunds Resulting From Other Insurance
- Co-insurance and Deductible
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- Services Utilization Review (SURS)
- Review of Services Utilized
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- 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
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- 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
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- Prior Authorization (PA)
- PA Instructions
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- Claim Correction Form (CCF)
- CCF Instructions
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- Remittance Advice (RA)
- Banner Page
- Paid, Denied, Claims in Process
- Adjusted Claims
- Financial Items
- TPL and Medicare
- Earnings Data and Error Messages
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- 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.
Allergy Testing and Desensitization
Anesthesia Services
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
Recertification
Reimbursement Guidelines
Surgery
Prior Approval Criteria for Surgical Procedures
Augmentation
Mammoplasty
Blephaoplasty
Breast
Reconstruction
Dermabrasion
Gastric Bypass
Surgery
Panniculectomy
and Lipectomy
Penile
Prosthesis
Radiology
Services
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
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 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
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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.
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