CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Diabetes Self-Management Education Mandate

Defines Rhode Island-mandated coverage for diabetes self-management education and related billing/coding for Commercial products offered in Rhode Island; describes who may provide services, settings, and reimbursement codes. Affects providers billing Blue Cross & Blue Shield of Rhode Island commercial plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDiabetes Self-Management Education Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 1999

Next Review DateN/A

Key ActionVerify member benefits in the Benefit Booklet/Evidence of Coverage before providing diabetes education services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CommercialApplies to plan type

No prior authPrior authorization requirement

Group: 2+G0109 (group)

Per 30 minG0108 (individual)

Coverage criteria and limits

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Covered DSME criteria

Covered when ALL of the following are met

Provider and prescription: Education must be medically necessary and prescribed by a physician; may be provided by the physician or, upon referral, an appropriately licensed and certified health care provider.

Supported by RIGL 27-20-30

Setting: May be conducted in individual sessions, group sessions, or home visits when medically necessary.

Includes group, individual, and home visit settings per mandate

Timing/indication: Covered at diagnosis, when a physician documents a significant change in symptoms/condition necessitating changes in self-management, or when reeducation/refresher is necessary.

Coverage limited to medically necessary visits as defined by statute

Provider qualifications and program structure: Typical pre-assessment evaluation by a certified diabetes educator and program structures described (typical group: seven 2-hour sessions; typical individual: five 1-hour sessions).

Descriptive guidance; educational program should be developed following pre-assessment

Benefit plans offered by a hospital service corporation may impose copayments and/or deductibles for benefits mandated by Rhode Island law; however, in no instance shall the copayment or deductible amount exceed the copayment or deductible amount imposed for other supplies, equipment, or physician office visits. Providers should apply the same member cost-sharing limits to these mandated diabetes-related supplies and equipment as they do for comparable items and visits.

If services are determined to be not medically necessary, or if the services are non-covered benefits under the member’s contract, those services may be denied. Providers may not bill the member for such denied services unless the provider informed the member in advance and the member agreed to accept financial responsibility. Verify member-specific benefits and any applicable participation agreement provisions before billing.

Billing and coding guidance

Covered G codes (professional providers)CPTCovered

G0109	Diabetes outpatient self-management training services, group session (2 Or more), per 30 minutes
G0108	Diabetes outpatient self-management training services, individual, per 30 minutes

S code (not separately reimbursed if billed with E&M)HCPCS

S9141

Diabetic management program, follow-up visit to MD provider

Covered S codes (institutional providers)HCPCSCovered

S9455	Diabetic management program; group session
S9140	Diabetic management program, follow-up visit to non-MD provider
S9460	Diabetic management program; nurse visit
S9465	Diabetic management program; dietitian visit

What providers must do

Prior Authorization

Prior authorization review is not required for Diabetes Self-Management Education (DSME) for covered Commercial products.

Documentation Required

Medical Necessity Conditions

Coverage for DSME is limited to medically necessary visits. Medical necessity includes visits at initial diagnosis, when a physician documents a significant change in the patient’s symptoms or condition that necessitates self-management education, when reeducation or refresher training is necessary, and when home visits are medically necessary and prescribed by a physician. Education must be prescribed by a physician and may be provided by the physician or, upon referral, by an appropriately licensed and certified health care provider; group settings are permitted.

Note

Verify Member Benefits

The State of Rhode Island (Nonprofit Medical Service Corporations: Section 27-20-30) requires coverage of diabetes self-management education for Commercial products; however, benefits may vary by group or contract and self-funded groups may choose not to follow the state mandate. Verify member-specific benefits and coverage in the applicable Benefit Booklet, Evidence of Coverage/Subscriber Agreement, or Explanation of Benefits prior to providing services.

Denial Risk

Member Billing / Denial Risk

If services are determined to be not medically necessary or are non-covered benefits, the service may be denied and the provider may not bill the member for those services unless the member was informed and agreed in advance to pay at their own expense. Refer to participation and provider agreements for applicable billing provisions and confirm member eligibility and benefit details before rendering DSME services.

Legislative and policy background

Rhode Island law (Nonprofit Medical Service Corporations: Section 27-20-30) requires coverage of diabetes equipment, supplies, and diabetes self-management education (DSME), including medical nutrition therapy, to instruct persons with diabetes in self-management. DSME must be prescribed by a physician and may be provided by the physician or, upon referral, by appropriately licensed and certified health care providers (for example, a state-certified diabetes educator). Services may be delivered in individual sessions, group sessions, or home visits when medically necessary.

Definitions and qualified providers

Medically necessary DSME

DefinitionEducation limited to medically necessary visits: at diagnosis, when a physician documents a significant change in symptoms/condition necessitating changes in self-management, or when reeducation/refresher is necessary; must be prescribed by a physician to be covered.

ScopeIncludes diabetes self-management education and medical nutrition therapy when medically necessary.

SettingsMay be conducted in individual sessions, group sessions, or home visits when medically necessary.

Prescription requirementMust be prescribed by a physician to be covered.

Regulatory basisMandated under Rhode Island law (Nonprofit Medical Service Corporations: Section 27-20-30).

Providers qualified to deliver DSME

Primary providersPhysician may provide diabetes self-management education directly.

Referral providersUpon referral by a physician, appropriately licensed and certified health care providers may provide DSME (e.g., state-certified diabetes educator).

Qualification exampleState-certified diabetes educator cited as an example of an appropriately licensed and certified provider.

Coverage conditionEducation provided by these providers is covered only when medically necessary and prescribed by a physician.