CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) — Diabetic Supplies Coverage Criteria

Lists durable medical equipment (DME) diabetic supplies covered by Neighborhood Health Plan of Rhode Island's Dual CONNECT (HMO D-SNP) and describes access via participating pharmacies/vendors; applies to members of the Dual CONNECT plan and their prescribing providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) — Diabetic Supplies Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain a provider prescription and verify prior authorization or quantity limits with the plan or participating vendor when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

listcovered diabetic DME products enumerated in policy

participating vendorswhere supplies can be obtained

possibleprior authorization or quantity limits

Coverage Criteria

Coverage criteria for listed diabetic DME supplies

Covered when ALL of the following are met

General requirements: Item is a diabetic supply listed in the policy or is determined medically necessary; prescribed by a provider; obtained at a participating pharmacy or participating DME vendor; prior authorization and applicable quantity limits complied with when required.

Covered supplies are not limited by brand when filled at a participating DME vendor. Providers may request coverage for medically necessary items not listed in the policy.

Some DME diabetic supplies are not individually listed in this policy but may still be covered when considered medically necessary. Providers may request coverage for non-listed diabetic supplies by documenting medical necessity and working with Neighborhood Health Plan of Rhode Island to obtain plan approval. Covered diabetic supplies are not limited by brand or manufacturer when filled at a participating DME vendor.

This document does not specify any items that are explicitly designated as not medically necessary. Instead, it affirms that some items not listed may be covered if determined medically necessary and invites providers to request coverage determinations from the plan.

Product / Coding List

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) — Diabetic Supplies Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain a provider prescription and verify prior authorization or quantity limits with the plan or participating vendor when applicable.

SourceLink

On This Page

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Covered Products (brand-level)mixedCovered

LANCETS	ANY
ACCU-CHEK AVIVA PLUS TEST STRIPS	ROCHE DIAG
ACCU-CHEK GUIDE TEST STRIPS	ROCHE DIAG
ACCU-CHEK SMARTVIEW TEST STRIPS	ROCHE DIAG
ACCU-CHEK COMPACT PLUS TEST STRIPS	ROCHE DIAG
ACCU-CHEK GUIDE METER	ROCHE DIAG
ACCU-CHEK GUIDE ME METER	ROCHE DIAG
ACCU-CHEK AVIVA PLUS METER	ROCHE DIAG
ACCU-CHEK NANO METER	ROCHE DIAG
ACCU-CHEK CONTROL SOLUTION	ANY ACCU-CHEK

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Provider Actions & Authorization

Prior Authorization

Prior Authorization & Quantity Limits

Prior authorization may be required — verify requirements with Neighborhood Health Plan of Rhode Island before ordering or dispensing DME diabetic supplies. Products may be subject to prior authorization and/or quantity limits; failure to obtain required authorization can result in claim denial or limits being enforced.

Some products listed as covered may still require prior authorization or have quantity limits.
Verify participating DME vendor or pharmacy participation and prescription requirements before filling.
Contact Member Services at 1-844-812-6896 (TTY 711) or view the Neighborhood CONNECT Provider and Pharmacy Directory at www.nhpri.org/DualCONNECT for vendor/pharmacy participation and authorization guidance.

Documentation Required

Prescription Requirement

A prescription from a provider is required to obtain DME diabetic supplies at a participating pharmacy or DME vendor.

Denial Risk

Prior Authorization and Quantity Limits

Products may be subject to prior authorization and/or quantity limits; noncompliance can trigger denial or limit enforcement. If a needed DME diabetic supply is not listed, providers may request coverage when it is medically necessary.

Covered diabetic supplies are not limited by brand or manufacturer when filled at a participating DME vendor.
Providers may submit a medical necessity request for items not listed.

Background

The policy lists covered diabetes-related DME supplies available to members when prescribed, including but not limited to blood glucose meters, continuous glucose monitoring sensors and meters, insulin pump systems and supplies, test strips, lancets, and control solutions. These supplies can be obtained at a participating pharmacy or participating DME vendor with a prescription.

Definitions

Participating DME vendor or pharmacy definition

DefinitionParticipating DME vendor or pharmacy that contracts with Neighborhood to provide covered diabetic supplies.

Place of serviceCovered diabetic supplies can be obtained at a participating pharmacy or participating DME vendor when filled at a participating vendor.

Brand policyCovered diabetic supplies are not limited by brand or manufacturer when filled at a participating DME vendor.

How to find vendorsTo view participating DME vendors and pharmacies, use the Neighborhood CONNECT Provider and Pharmacy Directory at www.nhpri.org/DualCONNECT or call Member Services at 1-844-812-6896 (TTY 711).

Medical Necessity for Non-Listed Supplies

Medical necessity for non-listed supplies

Medical necessity coverage applies when items are prescribed and determined necessary by the plan; the document does not specify detailed clinical criteria.

Medical necessity: Provider documents medical need for a diabetic supply not listed in the policy or documents medical justification for quantities beyond standard limits; plan approves based on medical necessity review.

Providers may work with Neighborhood to request coverage for DME diabetic supplies not included in the listed items. Prior authorization/quantity limit policies apply when relevant.

Rental and Purchase Rules

Rule	Details
Rental vs. purchase policy specified
Document does not specify rental versus purchase rules or capped rental arrangements for diabetic DME supplies. Providers and members should contact Neighborhood or refer to the participating DME vendor for billing/rental arrangements.

Replacement

Replacement details

Replacement interval detailsNot specified in the policy document (replacement intervals and item-specific replacement rules are not provided).

Prior authorization impactSome products may be subject to prior authorization and/or quantity limits; replacement requests may be subject to the same authorization/quantity policies.

Medical necessity for non-listed itemsProviders may request coverage for diabetic supplies not listed; coverage for replacements of non-listed items requires determination of medical necessity by Neighborhood.

Documentation & Prescribing Requirements

Documentation Required

Maintain prescription and comply with authorization/quantity rules

Ensure the member’s prescription is on file and follow any applicable prior authorization and quantity limit policies when ordering or dispensing covered diabetic supplies.

Confirm participating pharmacy or DME vendor status via the Neighborhood CONNECT directory or Member Services.
Obtain prior authorization when indicated by the plan or vendor before dispensing.

Not Covered

There are no explicit equipment items or situations listed as not covered in this document. The policy instead states that some supplies not listed may be covered if medically necessary and that providers should request coverage for non-listed items as appropriate.