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May 30, 2019

Medicare Diabetes Prevention Program: Valid Claims

Note: This article was previously published in the May 23, 2019, edition of the CMS MLN Connects®External Website

For a claim to be valid under the Medicare Diabetes Prevention Program (MDPP), you must have both:

Important:

If you do not have a separate Medicare enrollment as an MDPP supplier and you submit a claim for MDPP services, your claim will be rejected.

Medicare enrolled MDPP suppliers: See the Quick Reference Guide to Payment and BillingExternal PDF and the Billing and Claims Fact SheetExternal PDF for information on valid claims:

  • MDPP Medicare beneficiary eligibility data is returned via the HIPAA Eligibility Transaction System (HETS)External Website on the 271 response; use this data to determine if a beneficiary meets the criteria to receive MDPP services
  • Submit claims when a performance goal is met, and report codes only once per eligible beneficiary (except G9890 and G9891)
  • List each HCPCS code with the corresponding session date of service and the coach's National Provider Identifier (NPI)
  • List all HCPCS codes associated with a performance payment (including non-payable codes) on the same claim
  • Include Demo code 82 in block 19 (Loop 2300 segment REF01 (P4) and segment REF02 (82)) to identify MDPP services
  • Do not include codes for other, non-MDPP services on the same claim

Trouble with MDPP billing and claims:

  • Some MDPP claims are being denied as a result of a systems issue
  • Medicare Administrative Contractors (MACs) are manually processing these claims through October 2019 until the fix is implemented
  • Contact your MACExternal Website with questions

For More Information:

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