Please see the June 2024 Provider Update from Medicaid. All previous provider updates are available online. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Please see the April 2024 Provider Update from Medicaid. All previous provider updates may also be on this webpage.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Please see the March 2024 Provider Update RI Medicaid. All previous provider updates may also be found here.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Please see the most recent Medicaid Provider Update (January 2024). All provider updates dated back to 2019 are available online.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Please see the November 2023 provider update. Previous updates can also be found on the Executive Officer of Health and Human Services (EOHHS) Provider Updates web page.  

Also in Rhode Island, Medicaid has noticed an increase in the number of Continuous Glucose Monitors (CGMs) submitted via pharmacy claims. Please note that Medicaid considers CGMs as DME products and requires prior authorization for all CGM-related items. All prior authorization requests must be submitted by the dispensing provider and must include a prescription and recent clinical notes. Requests submitted directly by ordering physicians will be returned. 

• Coverage guidelines can be found here: CGM Policy Final 091222.pdf (ri.gov) 
• Prior authorization forms and instructions can be found here: Prior Authorization | Executive Office of Health and Human Services  

In adherence with recent Medicare HCPCS code updates, Medicaid activated the following CGM codes: 

• A4239 – SUPPLY ALLOWANCE FOR NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE 
• E2103 – NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR OR RECEIVER  

Effective October 1, 2023, prior authorization requests submitted under codes K0553 and/or K0554 are being returned and must be resubmitted with the proper codes. 

Claim submission for reimbursement must be done using either the 837 professional file format or via the CMS 1500 paper claim. Claims submitted otherwise will be denied. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Please see the most recent Provider Update for Medicaid. All provider updates may also be found here.  

Also in Rhode Island, effective October 1, 2023, Katie Beckett recipients will now be enrolled in a managed care organization for Case Management Services only. Case Management services are provided by CEDARR Center Providers. All other services will still be reimbursed through Medicaid fee for service.  

When checking eligibility on the Healthcare Portal (HCP) you will see the following (see sample picture below): 

1. A new row under Benefit Plan Details – Katie Beckett Case Management
2. A new row under Managed Care Details – Displays the name and dates of the Managed Care Plan the recipient is enrolled in. 

If you are a CEDARR provider and the recipient is enrolled in the Katie Beckett case management program, then you must bill your services to the managed care plan on file. All other providers will continue to bill Medicaid Fee for Service. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The state issued a Provider update. Please find here the link to the August Provider Update.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Medicaid is preparing to implement the Real Time 270/271 Eligibility Verification Request and Response and Real Time 276/277 Claim Status Request and Response Transactions. For Real Time transactions, the sender remains connected while the receiver processes the transactions and returns a response to the sender and with an average response time within 20 seconds. Gainwell will utilize a Real Time Safe Harbor interface referred to as HDE (Health Direct EDI). This will allow for trading partners to transmit the Real Time transactions directly to the translator (EDIaaS). 

 HDE connectivity and requirements per CAQH Core Rules 

• Trading Partner Software web service to process transaction 
• Trading Partner transaction can be in SoapUI or MIME format for submission
• Trading Partner will receive a URL, HDE username and password to access the HDE connection. 

What does this mean? If you are a provider, contact your software vendor, clearing house or billing agency. Medicaid does not offer software for these Real Time transactions.  

To participate  

• Do you have a trading partner number?  
• Is your contact information on the Healthcare Portal current? 
• If you have answered yes to the above questions and are interested in these Real Time transactions, please answer the questions below. 

Testing will begin late July to mid-August. 

To participate in testing, you must provide the information below. 

Name, TPID, contact name, email, and telephone number. Identify format (SOAPUI or MIME) for submitting Real Time transactions.  

Send your answers to riediservices@gainwelltechnologies.com. Please make sure to add a subject line of Real Time Transactions.  

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The June 2023 provider update can be found here. Previous issues can be found on the EOHHS [Executive Office of Health & Human Services] website at the provided link above. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.