Waiver 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.

Waiver Services Coverage Policy
       Provider Participation Guidelines
       Recertification
       Reimbursement Guidelines
       Claims Billing Guidelines
       Co-Insurance, Deductible and Co-Payments
       Patient Liability

Aged and Disabled Waiver
       Introduction
       Reimbursement Guidelines
       Covered Services
       Limitations/Special Requirements
       Retroactive Authorization

Department of Elderly Affairs Waiver
       Introduction
       Reimbursement Guidelines
       Nursing Home and Community Residents
       Covered Services
       Limitations/Special Requirements
       Retroactive Authorization
       Eligibility Assessment: Level of Care

Mentally Retarded, Devlopmentally Disabled Waiver
       Introduction
       Reimbursement Guidelines        
       Covered Services
       Limitations/Special Requirements
       Retroactive Authorization

Severely Handicapped Waiver
       Introduction
       Reimbursement Guidelines        
       Covered Services
       Limitations/Special Requirements
       Retroactive Authorization

Claim Preparation Instructions

Waiver Form Filing Instuctions
Waiver Services – Waiver/Rehab Claim Form

 

CMS 1500 Form Filing Instructions

Waiver 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

 

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.