CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicare Diabetes Prevention Program (MDPP) coverage and reimbursement

Defines Neighborhood Health Plan of Rhode Island coverage, payment, coding, and documentation requirements for MDPP services furnished by CDC/MDPP-recognized providers for eligible members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicare Diabetes Prevention Program (MDPP) coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide MDPP services only when members meet eligibility criteria, are served by a CDC/MDPP-recognized provider, and maintain required documentation for each session.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Session phases

once per lifetimeBenefit limit

>=25BMI threshold

5% & 9%Incentive targets

0Prior authorization

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Continuation / Performance Incentives

Continuation and incentive criteria:

Ongoing maintenance eligibility: Member must achieve a minimum 5% weight (BMI) reduction from baseline during the Core Sessions and maintain that 5% reduction to be eligible for Ongoing Maintenance sessions5% weight loss maintained

Performance incentives are payable for achieving 5% and 9% weight loss; attendance-based reimbursement applies for core sessions as defined by HCPCS G-codes

Coverage excludes members with a prior diagnosis of diabetes (diagnosis present on or before the start date of the first core session), members with a diagnosis of End Stage Renal Disease (ESRD), members who are not covered under the specified line of business (INTEGRITY), and members who have previously received MDPP services.

MDPP services are not medically necessary for members who have an existing diagnosis of diabetes at or before the start date of the first core session, or for members diagnosed with ESRD. These situations are specified as exclusions under the Coverage and Payment Policy and will render MDPP services non‑covered for those members.

Billing Codes, Thresholds, and Related Criteria

Covered HCPCS G-codes for MDPP sessions and performanceHCPCSCovered

G9873	1st core session attended.
G9874	4 total core sessions attended.
G9875	9 total core sessions attended.
G9876	2 core maintenance sessions attended in months 7-9 (weight loss not achieved or maintained).
G9877	2 core maintenance sessions attended in months 10-12 (weight loss not achieved or maintained).
G9878	2 core maintenance sessions attended in months 7-9 and weight loss goal achieved or maintained.
G9879	2 core maintenance sessions attended in months 10-12 and weight loss achieved or maintained.
G9880	5 percent weight loss from baseline achieved.
G9881	9 percent weight loss from baseline achieved.
G9883	2 ongoing maintenance sessions attended in months 16-18 and weight loss maintained goal.

1–10 of 14

1/2

BMI and weight-loss thresholds

BMI eligibilityBMI >=25 on date of first core session (>=23 if self-identified as Asian).

Glycemic entry criteriaQualifying glycemic test within 12 months before first core session: HbA1c 5.7%–6.4% OR fasting plasma glucose 110–125 mg/dL OR 2‑hour OGTT 140–199 mg/dL.

Prior diabetes diagnosis exclusionNo prior diagnosis of diabetes on date of first core session (gestational diabetes excluded).

Ongoing maintenance entryMember must achieve a minimum 5% weight (BMI) reduction from baseline to be eligible for Ongoing Maintenance sessions.

Ongoing maintenance maintenance requirementMember must maintain the 5% BMI/weight reduction for the duration of Ongoing Maintenance sessions (months 13–24).

Provider Requirements, Billing, and Documentation

Prior Authorization

MDPP services do not require prior authorization.

Billing Rule

Payment and incentives

Neighborhood reimburses MDPP claims on a Fee‑For‑Service basis as specified by the provider contract. In addition to base FFS reimbursement, providers may be eligible for performance‑based incentive payments where specified in contract or program agreements — confirm incentive availability, metrics, and payment timing with the Neighborhood provider contract manager.

Payment method: Fee‑For‑Service (per provider contract)
Performance incentives: potential additional payments subject to contract/program terms — verify metrics and eligibility

Documentation Required

Required MDPP record elements

To qualify for reimbursement, providers must maintain a treatment record for each member receiving MDPP services that meets state and federal requirements. Required record elements include member identification (Neighborhood ID, name), documentation of medical necessity, coach/facilitator name, date and place of service, recording of member weight at each session, and other session details. Records must be accurate, legible, and signed within 30 days of service. Neighborhood may request patient records at any time for audit and compliance; any additions or edits to records must follow CMS Medicare Program Integrity Manual Chapter 3.

Member identification (Neighborhood ID, name)
Documentation of medical necessity
Coach leading the session
Date and place of service
Recording of member weight at each session
Session details and attendance
Records completed and signed within 30 days of service
Edits/additions must comply with CMS Medicare Program Integrity Manual Chapter 3

Denial Risk

Eligibility-related denial triggers

MDPP services have a maximum limit of once per lifetime. Claims may be denied if the member has previously received MDPP services, is diagnosed with End Stage Renal Disease (ESRD) when excluded by policy, or is not covered by Neighborhood. Verify member eligibility and prior MDPP receipt before billing.

Benefit limitation: MDPP services limited to once per lifetime
Denial triggers: prior receipt of MDPP services
Denial triggers: member not covered by Neighborhood
Denial triggers: members with ESRD where excluded by policy

Program Background

The Medicare Diabetes Prevention Program (MDPP) delivers a structured, CDC‑approved lifestyle curriculum and coaching intended to reduce progression to type 2 diabetes through weight loss and behavior change. The program is delivered over a maximum of 24 months divided into three phases: Core (months 0–6), Core Maintenance (months 7–12), and Ongoing Maintenance (months 13–24). The MDPP requires provider recognition by CDC/MDPP and focuses on sustained weight reduction and lifestyle modification to lower diabetes risk.