Rhode Island RI

Bryan fieldwork 2026-06-07. RI Medicaid PA sources (better than the generic eohhs.ri.gov/ homepage we had pinned): pharmacy PA program at eohhs.ri.gov/providers-partners/provider-directories/pharmacy/pharmacy-prior-authorization-program. RADIOLOGY carve-out: eviCore administers PA for ALL outpatient MR, CT, PET imaging for all RI Medical Assistance participants (since 2008-01-01); nuclear cardiology EXEMPT. Sample medical criteria seen: Biomarker testing (covered when result informs treatment/monitoring + medical-necessity supported; requires face-to-face visit within 30 days OR tumor-board/specialist recommendation; clinical-trial/experimental biomarker testing denied).

Rhode Island Medicaid (EOHHS) expresses prior authorization through the Medicaid Provider Manual hub, NOT a single PA code list. FFS PA authority is EOHHS; Gainwell Technologies is the fiscal agent (PA forms faxed to 401-784-3892 / mailed to Gainwell PA, PO Box 2010, Warwick RI 02887-2010, or via the RI Medicaid Healthcare Portal). Canonical PA hub: /providers-partners/billing-and-claims/prior-authorization — general PA Form + Instructions, plus program-specific criteria for Biomarker Testing, DME, Hospital, Pharmacy, Radiology. Clinical PA CRITERIA live two ways: (1) HTML pages inside per-service provider manuals — e.g. Physician manual 'Prior Approval (PA) Criteria For Surgical Procedures' lists per-procedure coverage/approval/denial criteria (augmentation mammoplasty, bariatric, blepharoplasty, gender-affirming surgeries, panniculectomy, reduction mammoplasty, rhinoplasty/septoplasty); (2) downloadable PDF reference manuals per service (General Guidelines, OT/Speech reference manuals, Biomarker PA). Standard PA SLA = 7 days; expedited/urgent = 72 hours. Outcomes: Approved / Modified / Denied. RIte Care MCOs (Neighborhood Health Plan of RI, Tufts Health, UnitedHealthcare Community Plan) run their own PA for managed-care members; pharmacy is per-MCO PBM aligned to state PDL. IMPORTANT: previously pinned pa_index URL (.../billing-claims/prior-authorization) is DEAD (404). Live path: .../billing-and-claims/prior-authorization (note 'billing-and-claims').

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2024-07-16. Next due: TBD (no target reprocurement date announced as of late 2025).

## 1. How RI requires PA Rhode Island (RI) Medicaid requires prior authorization (PA) for various services and procedures to ensure medical necessity and cost-effectiveness. Key requirements include: - **Pharmacy Services**: There is no carve-out for pharmacy services, meaning these are subject to the same PA processes as other services. - **Behavioral Health (BH)**: BH services are carved into Managed Care Organizations (MCOs), requiring PA through MCO channels. - **Long-Term Services and Supports (LTSS)**: LTSS services were transitioning to be carved into MCOs, effective July 1, 2025. - **Foster Care Program**: The foster-care program is managed by RIte Care for Children in Substitute Care, but specific PA requirements are not detailed in the findings. - **Investigational/Experimental Medical Procedures**: These require a Certificate of Medical Necessity and do not involve step therapy. - **Ophthalmologic and Diagnostic Tests**: Non-emergency services exceeding $500 require PA with documentation on medical necessity, diagnosis, and comparison to lower-cost alternatives. - **Surgical Services**: Specific surgeries like Augmentation Mammoplasty for benign disease or mastectomy with prosthesis, Bariatric Surgery (BMI ≥40 kg/m² or ≥35 kg/m² with comorbidities), and Cosmetic Follow-Up (Blepharoplasty) post-bariatric surgery have specific PA requirements. - **Dental Treatment**: Dental services require meeting clinical coverage criteria, though no step therapy is applicable. ## 2. How RI publishes and reports PA RI Medicaid publishes its PA requirements through the EOHHS Provider Manual, which includes per-service reference guides and HTML surgical criteria. The provider manual serves as the primary hub for understanding PA processes and criteria. Specific documents include: - **Provider Manual**: Available at [https://eohhs.ri.gov/providers-partners/provider-manuals-guidelines/medicaid-provider-manual](https://eohhs.ri.gov/providers-partners/provider-manuals-guidelines/medicaid-provider-manual), this manual contains detailed guidelines and criteria for various services. - **PA Form**: The Rhode Island Medicaid Prior-Authorization form (PA_form_july2025.pdf) is used for outpatient services, requiring medical necessity documentation and step therapy. It was revised in April 2025. - **Denial Reference Document**: This document outlines denial reason codes and next steps, such as Denial Reason Code 0004 indicating the request does not meet policy coverage criteria. ## 3. RI's CMS-0057-F and PA-reform compliance posture Rhode Island is in the process of implementing changes to its PA system through the Rhode Island Prior Authorization Reform Act of 2025 (HB 5120 / SB 0168, per source documents). The state's posture relative to CMS-0057-F includes: - **Behavioral Health and LTSS**: BH services are carved into MCOs. LTSS services have transitioned to be carved into MCOs effective July 1, 2025. - **Prior Authorization Reform Act**: The Rhode Island Prior Authorization Reform Act aims to streamline and improve PA processes. **WISeR is not applicable to RI** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. ## 4. How RI runs its own program Rhode Island Medicaid operates through a combination of Managed Care Organizations (MCOs) and Fee-for-Service (FFS) arrangements: - **Managed Care Organizations**: The state awards MCO contracts every five years, with the last award made on July 16, 2024. No specific target reprocurement date has been announced as of late 2025. - **Fee-for-Service (FFS)**: RI Medicaid uses Gainwell Technologies as its fiscal agent for FFS operations. PA forms can be submitted via fax to 401-784-3892, mail to Gainwell PA, PO Box 2010, Warwick RI 02887-2010, or through an unspecified portal. - **Fiscal Agent History**: The state has transitioned from ACS-Inc to Conduent/Gainwell as its fiscal agent over time. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Comprehensive Provider Manual**: RI Medicaid relies heavily on the EOHHS Provider Manual for detailed PA criteria and guidelines. - **Frequent Updates**: The state frequently revises its PA forms and guidelines, with updates in April 2025 and November 2020 reflecting ongoing efforts to improve processes. - **Behavioral Health and LTSS Carve-ins**: BH and LTSS services are carved into MCOs. ### What's Missing/Uncertain: - **Specific Foster Care Program Details**: While RIte Care for Children in Substitute Care manages foster care, specific PA requirements are not detailed. - **Prior Authorization Reform Act Implementation**: Although the Act has been enacted (per source documents), details on its implementation and impact are not provided. - **1115 Waiver Details**: The Rhode Island Comprehensive Demonstration (1115 waiver) is mentioned but lacks specific information on how it affects PA processes. These gaps highlight areas where further research or clarification would be beneficial to fully understand RI Medicaid's PA system.