Rhode Island behavioral health billing

Rhode Island behavioral health billing for community providers.

HRI bills Rhode Island Medicaid behavioral health claims, mental health and substance use, from enrollment through appeals: the state's rules and each plan's rules read together, authorization tracked to the date, and every claim reported each Friday.

Updated September 2026

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What Rhode Island billing runs on

One state agency and three Medicaid plans, read together
A BHDDH license, then Medicaid enrollment, then plan contracts
Per diem programs, and a different notice rule at each plan
Every claim reported every Friday

How Rhode Island Medicaid pays behavioral health

Rhode Island Medicaid is run by the Executive Office of Health and Human Services (EOHHS). Gainwell Technologies is the state's fiscal agent: it runs provider enrollment and processes fee-for-service claims. Most members get their care through one of three managed care plans: Neighborhood Health Plan of Rhode Island, Tufts Health Public Plans (its Medicaid product is Tufts Health RITogether) and UnitedHealthcare Community Plan. Some members stay in fee-for-service, for example members with Medicare who choose to, and members whose employer insurance Medicaid wraps around.

Behavioral health is not handled the same way at each plan. Neighborhood manages behavioral health itself for dates of service on or after September 1, 2025; before that, its behavioral health claims went to Optum. UnitedHealthcare Community Plan's mental health and substance use benefit runs through Optum. Tufts has its own behavioral health prior authorization grid and phone line for Tufts Health RITogether. So a claim answers to two sets of rules: the state's licensing and enrollment rules, and the plan's own rules for codes, notice and filing.

The agency that licenses adult behavioral health programs and substance use programs is the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, known as BHDDH. Its rule covers behavioral health services for adults who are not in the custody of the Department of Children, Youth, and Families (DCYF), and substance use disorder services for children and adults. Programs licensed by DCYF are outside it, so for a children's mental health program, ask BHDDH and DCYF which license applies before you plan.

Before the first claim: license, enrollment, plan contracts

For a new program the order is fixed, and each step needs the one before it: a BHDDH license, then Rhode Island Medicaid enrollment, then a contract and credentialing with each plan you want to bill. Neighborhood says it starts contracting only after Medicaid enrollment, and Tufts and Optum both tell providers to be screened by the state first.

BHDDH license: Programs that give clinical behavioral health care apply for a Behavioral Healthcare Organization license from BHDDH's Office of Licensure and Standards. A license runs for two years. Each service site needs its own application, with the State Fire Marshal's inspection report and a notarized list of every owner, officer and director with ownership percentages. BHDDH reviews the organization's board, staffing, background checks, financial disclosure, fiscal capacity and business plan, and written policies, and it makes readiness reviews and onsite visits. The application form has boxes for intensive outpatient and partial hospitalization, among other services.
What the rule asks of IOP and PHP: BHDDH's rule treats substance use IOP as ASAM level 2.1: at least nine hours a week of skilled treatment for each person, with at least one hour a week of individual counseling, and a treatment plan within 14 days of admission. PHP has to offer 20 hours a week of clinical treatment and scheduled programming, run at least five full days a week, and the facility must have national accreditation. Substance use PHP is ASAM level 2.5.
Medicaid provider type: Substance use programs enroll as provider type 060, Substance Abuse Rehab. Community mental health centers enroll as type 061, CMHC/Rehab Option, which also asks for MHPRR certification where it applies. Both need a BHDDH license and an NPI, and EOHHS rates both moderate risk. A group of clinicians under a BHDDH license enrolls as type 066, BHDDH Behavioral Health Group, which EOHHS rates limited risk. The EOHHS pages we read do not say which type a mental health IOP or PHP outside a community mental health center should use, so ask Gainwell's help desk before you apply.
Portal and documents: You apply in the Rhode Island Healthcare Portal, which Gainwell runs. The application is electronic only, and paper applications are not accepted. Have your NPI, addresses with ZIP+4, taxonomy codes, tax ID, license number, a signed W-9 and the federally required disclosures ready. A saved application is deleted if it is not finished within 30 days. Once you are enrolled, you register as a trading partner to see eligibility, claim status and remittance advice. EOHHS also requires electronic funds transfer for payment.
Application fee: The fee is $750 per application for 2026 for types 060 and 061, paid by check to the State of Rhode Island with the provider's name and NPI. It does not apply if you are enrolled in Medicare or have paid an enrollment fee to another state's Medicaid program, and for a fee paid to another state you send proof of payment. EOHHS's 2026 fee list names type 066, but its enrollment grid and the fee list in the rule that takes effect October 6, 2026 do not, so ask before you file.
Site visit: Moderate-risk providers get an unannounced, in-person site visit. EOHHS's enrollment grid notes that a provider enrolled in Medicare's PECOS system may not need one, because EOHHS can rely on Medicare's screening. EOHHS checks the location, signs, posted hours, staffing, records, privacy and billing practices. A provider made up only of administrative staff is not treated as operational: a new program has to show how it will credential, train and supervise staff, and at least one qualified direct care person hired or identified. If the visit finds problems, EOHHS lists them in writing and gives 30 days to fix them.
Effective date: EOHHS sets the effective date, and it does not reach back far. Its enrollment page says retroactive enrollment is limited to the first day of the month in which the application is approved. A rule that takes effect October 6, 2026 goes further for new moderate-risk providers, which include substance use rehabilitation and community mental health center rehabilitation programs: their effective date is the date of the approved site visit.
How long it takes: EOHHS publishes no processing time. We found none on its enrollment page, its January 2026 enrollment FAQ or the enrollment rule. The plans publish their own credentialing times, below.
Revalidation: EOHHS notifies providers by mail when it is time to revalidate and lists the notices in its monthly Provider Update. Federal rules require revalidation at least every five years.
Enrollment pauses: EOHHS has paused approving new providers of some types for six months at a time: home care and personal care (types 65 and 72), hospice and home health, and home and center based therapeutic services and applied behavior analysis. None of the pauses names a community mental health center or a substance use program. If your program includes home or center based therapeutic services or ABA, read the enrollment page first.

Enrollment puts you in the state's system. It does not put you in a plan's network. Federal law requires managed care network providers to be enrolled with or screened by the state, and EOHHS warns that an incomplete screening application could cost a provider its managed care billing privileges. Optum's page says that if several plans contact you, you submit one state application. Each plan then contracts with you and credentials you on its own.

Joining each plan

Every plan contracts with you separately, after you are enrolled. This is what each plan's own pages said on September 29, 2026.

Neighborhood Health Plan of Rhode Island: You must be enrolled with Rhode Island Medicaid first. Behavioral health facilities, including substance use providers running IOP or PHP, use Neighborhood's Behavioral Health Facility Type Provider Application, and clinicians and groups use a separate one. Neighborhood says it answers within five business days, sends the contract through DocuSign, and sends a web address for credentialing and payment information. Credentialing starts when your application is complete and may take up to 45 calendar days. You cannot see patients as a network provider until you are approved and hold the countersigned contract, and after the contract is final it can take up to 14 business days for your information to reach its claims system, so wait before you submit claims. Before it contracts with an organization, and every three years after, Neighborhood checks state licensing and that the organization is accredited by a body approved by CMS, and the facility's medical director must be credentialed too.
Tufts Health RITogether: Get the state screening first. Then send Tufts its Ancillary Data Form for community mental health centers, substance use treatment centers and ABA services, plus a W-9, to its provider information department by email, and file a credentialing application in CAQH ProView. Tufts says to allow 45 days. Its Rhode Island Provider Services line is 844-301-4093.
UnitedHealthcare Community Plan: Behavioral health runs through Optum, and new providers start with the network information at providerexpress.com under Our Network. Once Gainwell approves your enrollment, email Optum's Rhode Island network management office, ask for the Medicaid network to be added to your profile, and attach Gainwell's approval letter. UnitedHealthcare's Rhode Island guide says a facility needs a current unrestricted license, review and approval by an accrediting body, malpractice coverage that meets contract minimums and no Medicare or Medicaid sanctions, and has to agree to a site visit if it is not accredited by the Joint Commission or another recognized agency. It also says you must finish credentialing before you treat its members. We found no published credentialing time.

The codes and units on a Rhode Island claim

EOHHS's Medicaid provider manual pages for rehabilitative services and substance abuse treatment still describe an older system, with Department of Health licensing and state-specific codes, so this page does not print codes from them. The plans publish their own code tables, and this page follows those. Rates are in fee schedules that change, so this page leaves them out. Confirm the plan's current table before you submit.

Mental health IOP: Neighborhood lists S9480 with revenue code 0905, intensive outpatient psychiatric services, per diem, mental health.
Substance use IOP: Neighborhood lists H0015 with revenue code 0906 for a program that operates at least 3 hours a day and at least 3 days a week on an individualized treatment plan. Tufts Health RITogether's payment policy lists H0015 as the SUD intensive outpatient program, per day, and S9480 as the behavioral health intensive outpatient program, per day, and says its TG modifier does not apply to Tufts Health RITogether.
PHP and day treatment: Neighborhood lists H0035 with revenue code 0912 or 0913, partial hospitalization, less than 24 hours, and says a PHP can be hospital-based or freestanding and runs 6 to 9 hours a day at least five days a week. Tufts lists H0035 as behavioral health and substance use partial hospital, per day, billed with revenue code 912, where one unit is a half day and two units are a full day, and lists H2012 for behavioral health day treatment, per hour.
Court-ordered treatment: Tufts Health RITogether requires modifier H9 on claims for court-ordered behavioral health or substance use treatment, and says no notification, authorization or concurrent review is required for that treatment.
Substance use residential: In fee-for-service, EOHHS pays residential care as a per diem tied to the ASAM level: H0018 with modifier UD for level 3.1, H0010 UD for 3.5 and H0011 UD for 3.7, on the 837 professional or a CMS-1500, with taxonomy 324500000X. For dates of service from January 1, 2026, Tufts Health RITogether lists the same codes and taxonomy and asks residential substance use providers to use a CMS-1500 with place of service 55.
Outpatient claim details: Neighborhood denies a claim that leaves the rendering provider field blank, wants the tax ID entered exactly as on the W-9 with the SY or EI qualifier, and requires electronic 837 claims with only one billing provider on each claim, under payer ID 05047.

Authorization and notice, plan by plan

Each plan sets its own rules, and the rules move. Read the current grid for the date of service, not last year's. This is what each plan's own documents said on September 29, 2026.

Neighborhood: For dates of service since September 1, 2025, Neighborhood manages behavioral health for all its lines of business. Its prior authorization page says out-of-network behavioral health providers must obtain authorization before services, and points to a Behavioral Health Prior Authorization Grid effective June 1, 2026. We found no in-network requirement stated on that page, and it tells you to enter each code in its search tool. Standard Medicaid decisions come within 7 calendar days, expedited ones within 3. A request after the service is accepted only within 7 calendar days of the service and before a claim reaches Neighborhood, or in extenuating circumstances.
Tufts Health RITogether: Its July 2026 grid is written for in-network providers: intensive outpatient and day or evening treatment need no authorization or notification, and providers just bill. Out-of-network providers must request authorization before services start. Partial hospitalization needs notice after the first visit: the facility contacts Tufts on the first business day after the first day of treatment and completes a medical necessity review for more days. For substance use residential care, levels 3.3 and 3.1 need notice within two business days of admission, and level 3.5 needs none for days 1 to 10 and a concurrent review from day 11. Tufts says it administratively denies payment when an in-network provider fails to get the required authorization or notice. In-network providers reach it by fax at 857.304.6404 or by phone at 844.301.4093.
UnitedHealthcare Community Plan: Its Rhode Island guide says members can use all behavioral health outpatient services, and that prior authorization may be required for more intensive services, day treatment or partial, inpatient or residential care, requested in its provider portal or through Provider Services at 1-855-766-0344. The public UnitedHealthcare and Optum pages we read give no code-level list for IOP or PHP, so confirm it in the portal before the first admission.
Fee-for-service: EOHHS answers standard prior authorization requests within 7 days and expedited or urgent ones within 72 hours.

Certified Community Behavioral Health Clinics

Rhode Island's Certified Community Behavioral Health Clinics (CCBHCs) launched on October 1, 2024. A CCBHC is an outpatient clinic certified by the state to offer expanded mental health and substance use services. Six organizations run the clinics: Community Care Alliance, Family Service of Rhode Island, Gateway Healthcare (Pawtucket, Johnston and South County), Newport Mental Health, The Providence Center and Thrive Behavioral Health.

A CCBHC is paid a monthly rate, not a day rate. It sends one claim per member per month with code T1041 on the first line and a population modifier: U3 for high acuity adults, U4 for high acuity children and youth, U5 for substance use disorder and U6 for the standard population. EOHHS requires this code and modifier across all plans and fee-for-service. Neighborhood's policy says only one line is reimbursed, and that a member cannot be in ACT or an integrated health home and a CCBHC in the same month.

The state accepts CCBHC certification applications only during announced application periods. Under the criteria that take effect October 1, 2026, an applicant needs, among other things, a BHDDH license or a pending application, national accreditation from the Joint Commission, CARF or the Council on Accreditation or a pending application, and at least three years of experience with evidence-based care for people with serious mental illness or complex substance use disorders, or a track record of person-centered, recovery-oriented care. A new IOP or PHP program starts with the license and enrollment steps above, not here.

Where Rhode Island claims break

In every case below the care was delivered and the claim still failed or was exposed.

Enrollment or contract not in place. Neighborhood says you cannot see patients as a network provider until you are credentialed and hold the countersigned contract, and to wait up to 14 business days after that before you submit claims. UnitedHealthcare says you must finish credentialing before you treat its members, and that not complying with the state's enrollment mandate can mean delayed or denied claims payment.
A date of service before the effective date. EOHHS's enrollment page limits retroactive enrollment to the first day of the month in which the application is approved, and the rule effective October 6, 2026 sets a new moderate-risk provider's date at the approved site visit. Do not count on billing for days before that date.
A missing rendering provider or a mismatched tax ID at Neighborhood. The rendering provider field cannot be blank, and the tax ID qualifier has to match the W-9. Neighborhood accepts electronic 837 claims only, with one billing provider per claim.
A partial hospitalization notice missed at Tufts. The facility has to contact Tufts on the first business day after the first day of treatment, and Tufts administratively denies payment when a required notice or authorization was not given.
Out-of-network care without authorization at Neighborhood. Out-of-network behavioral health providers must obtain authorization before services, and a request after the service has a 7 day window.
Court-ordered treatment without the H9 modifier at Tufts. Tufts Health RITogether wants H9 on those claims.
The wrong form for substance use residential care. From January 1, 2026, Tufts asks residential substance use providers for a CMS-1500 with place of service 55, and EOHHS and Tufts both list taxonomy 324500000X.
A CCBHC claim without T1041 on the first line. The monthly rate is triggered by that code and a population modifier, and EOHHS requires it across all plans and fee-for-service.
Other insurance not billed first. Medicaid is the payer of last resort. Tufts wants the primary insurer's explanation of payment with the claim.
A late claim. The filing windows differ. Neighborhood's manual says complete claims must be received within 180 days of the date of service unless the contract says otherwise. Tufts's manual, which covers its Massachusetts and Rhode Island plans, sets 90 calendar days for first submission by in-state, in-network providers, again subject to the contract. For fee-for-service, Gainwell must receive the claim within 365 days. UnitedHealthcare treats a rejected claim not corrected within 365 days of the date of service, or the period in your contract, as late billed.

What changes on October 6, 2026

EOHHS has filed a revised enrollment rule, 210-RICR-20-00-1, that takes effect that day. It writes down the enrollment and site visit process in more detail. These are the parts that matter to a behavioral health program. We did not find plan guidance on how the plans will apply it.

Effective date. A new moderate-risk provider's enrollment starts on the date of the approved site visit. For other providers it starts on the date a complete application is submitted, and backdating is limited to emergency care and successful appeals.
Payment while enrollment is pending. A managed care network provider may be paid for services for up to 120 days after it submits a complete application and before enrollment is finished, and payments stop at once if EOHHS denies the application. Neighborhood, for one, still says it starts contracting only after enrollment.
One application for each provider type and NPI. An organization uses a Type 2 NPI, and an unfinished application is purged after 30 days.
Telehealth only is not enough. A valid practice location is not a virtual office or a P.O. box. EOHHS does not enroll telehealth-only providers, except in extenuating circumstances it decides, because a provider that offers telehealth has to be able to offer services in person.
A new location needs a site visit. A moderate-risk provider adding or moving a practice location sends the change at least 30 days before the start date, or EOHHS may suspend or deny payment for the time the location runs without an approved visit.
A license lapse ends enrollment. Enrollment ends automatically when the license or certification expires, unless renewal information is filed first.
Revalidation and filing. Providers revalidate at least every five years, and CCBHCs every three years, starting in 2027. A provider that misses its revalidation date has its payments suspended. Claims are due within one calendar year of the date of service.

Read the rule again on the day you file, because rules get amended and this page is dated September 2026.

What we do about it

HRI runs Rhode Island behavioral health billing under HRI Managed. That means benefit verification, authorization and concurrent review tracked to the date, and claims built to the state's rules and each plan's rules before they go out. In Rhode Island it also means coding each program to the plan's own code table and putting each plan's notice rule on the calendar the day a program opens: the first business day after the first treatment day for Tufts partial hospitalization, for example. A denied or stuck claim runs through the same seven-point diagnostic we apply to every claim. Every claim is reported to you every Friday, with its status, its age and the next action.

Opening a Rhode Island program

The BHDDH license decides when you can apply, and the EOHHS site visit decides when enrollment can start, so start there. We prepare the Gainwell portal application and each plan's contract request and track each one to a decision. Your organization signs the Medicaid provider agreement in the portal.

One rule is fixed: no claim goes to a payer until that payer confirms enrollment and an effective date. We do not bill for a date of service before the effective date the state and the plan have confirmed. The order of work, what to have ready and the first 90 days are on the new-program billing page.

What it costs

Rhode Island billing is priced the same way as the rest of our billing, by who pays the claim. Any claim Rhode Island Medicaid pays, in whole or in part, directly or through a managed care plan, carries a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum. The Medicaid fee is never a percentage of what is billed or collected, and it is owed whether or not the claim pays. Commercial insurance and Medicare claims carry a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim. Payers pay you directly, and we never receive payer money. Ending the agreement early outside its own exit terms carries an early-exit fee, set in the agreement. There is no setup fee when your operation is ready as it stands. Credentialing and enrollment work is priced separately, per service, in writing.

On Rhode Island Medicaid claims, your fee follows the claims we file, not what payers pay. Your exact numbers are set on a written quote after a billing review.

What HRI will not do

We will not promise a plan's authorization decision, a reimbursement rate, or a license, enrollment or credentialing date. Those calls belong to the plan, EOHHS, BHDDH and DCYF. We will not bill a Rhode Island claim before enrollment and an effective date are confirmed. And we have no say in what level of care a patient gets: that decision belongs to your clinical team.

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Rhode Island billing, answered

What Rhode Island providers ask about billing.

What do we need before Rhode Island Medicaid will pay a new behavioral health program?

Four things, in order. First, a Behavioral Healthcare Organization license from BHDDH for each service site. Second, enrollment with Rhode Island Medicaid through the Healthcare Portal that Gainwell runs, which for substance use and community mental health programs usually means an in-person site visit and a $750 application fee. Third, a contract and credentialing with each plan you want to bill: Neighborhood, Tufts Health RITogether or UnitedHealthcare Community Plan. Fourth, a confirmed effective date. Enrollment and credentialing are separate steps, and enrollment does not put you in any plan's network.

Which Medicaid provider type does a new program enroll under?

Substance use programs enroll as provider type 060, Substance Abuse Rehab. Community mental health centers enroll as type 061, CMHC/Rehab Option. Both are rated moderate risk and both need a BHDDH license. A group of clinicians under a BHDDH license enrolls as type 066, BHDDH Behavioral Health Group. EOHHS's pages do not say which type a mental health IOP or PHP outside a community mental health center should use, so we confirm that with Gainwell before we file.

How long does Rhode Island Medicaid enrollment take?

EOHHS publishes no processing time. The plans publish their own: Neighborhood says credentialing may take up to 45 calendar days and Tufts says to allow 45 days, and Neighborhood says its information can take up to 14 more business days to reach its claims system after the contract is final. UnitedHealthcare and Optum publish none that we found. A new provider that needs a site visit also waits for that visit, which EOHHS does not announce ahead of time.

What changes on October 6, 2026?

A revised state enrollment rule takes effect. For a new substance use rehabilitation or community mental health rehabilitation provider, the effective date of enrollment becomes the date of the approved site visit. The rule also requires a separate application for each provider type and NPI, generally does not enroll telehealth-only providers, requires a site visit and 30 days' notice for a new practice location, and ends enrollment automatically when a license expires. Read the rule again on the day you file.

How are IOP and PHP billed to Rhode Island Medicaid plans?

The plans publish their own codes. Neighborhood lists S9480 with revenue code 0905 for mental health intensive outpatient, H0015 with 0906 for substance use intensive outpatient, and H0035 with 0912 or 0913 for partial hospitalization. Tufts lists H0015 and S9480 for intensive outpatient by the day, and H0035 for partial hospitalization with revenue code 912, where one unit is a half day and two units are a full day. BHDDH's license rule sets what each level of care has to offer: for substance use IOP, at least nine hours a week, and for PHP, 20 hours a week over at least five full days. CCBHCs bill a monthly rate under T1041 instead.

Do we need prior authorization for IOP or PHP?

It depends on the plan, and it changes. Tufts's July 2026 grid says that for an in-network provider IOP needs no authorization or notification, and PHP needs notice the first business day after the first day of treatment, with a medical necessity review for more days. Neighborhood's page says out-of-network behavioral health providers must obtain authorization before services and tells you to check each code in its search tool. UnitedHealthcare's Rhode Island guide says authorization may be required for more intensive services, day treatment or partial. Fee-for-service requests are answered within 7 days, or 72 hours when expedited.

Do you charge a percentage?

Not on Medicaid claims. Any claim Rhode Island Medicaid pays, in whole or in part, directly or through a managed care plan, carries a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum, never a percentage of what is billed or collected, and owed whether or not the claim pays. On commercial insurance and Medicare claims, we charge a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim goes out, and payers pay you directly.

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Last updated: September 29, 2026