CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Diabetes Prevention Program Payment Policy – Archive 4

Defines Neighborhood Health Plan of Rhode Island's coverage, reimbursement, provider recognition, member eligibility, documentation, coding and claim submission rules for CDC-approved MDPP services for INTEGRITY membership.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDiabetes Prevention Program Payment Policy – Archive 4

Policy CodePolicy N/A

Change TypeAnnual review / formatting updates

Effective Date

Next Review Date

Key ActionVerify member eligibility, coverage and authorization prior to rendering MDPP services and maintain required treatment records including weights and session details.

SourceLink

POLICY UPDATE CHANGES

09/05/2023 Annual Policy Review Date. No Content Changes.

10/01/2022 Annual Policy Review Date. No Content Changes.

05/25/2021 Policy Review. Format Updated. No Content Changes.

04/01/2018 Policy Created

1Lifetime limit (per member)

>=25BMI eligibility threshold

5%Minimum weight loss for maintenance eligibility

9%Weight loss target for extended incentive

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Policy summary

Policy Subject: Medicare Diabetes Prevention Program (MDPP) payment and billing requirements. Status: CURRENT. This policy governs Neighborhood Health Plan of Rhode Island's coverage and Fee‑For‑Service reimbursement requirements for the MDPP Expanded Model as applied to INTEGRITY membership. The MDPP is delivered by CDC‑approved curricula and eligible MDPP coaches and is structured into three service phases over a 24‑month period: Core Sessions (months 0–6), Core Maintenance Sessions (months 7–12), and Ongoing Maintenance Sessions (months 13–24). Coverage, coding and documentation align with CMS coding standards (HCPCS/CPT/ICD‑10‑CM) and Neighborhood follows CMS documentation and medical necessity requirements. Payer context: Neighborhood (Neighborhood Health Plan of Rhode Island) administers the program for INTEGRITY members and requires provider recognition (MDPP or CDC recognition levels), member eligibility verification, timely claim submission on CMS‑1500 or electronic 837P, and maintenance of treatment records; performance incentive and session HCPCS codes (G9873–G9891) are used per CMS guidance.

Key thresholds & dates

Lifetime limit (per member)1 (once per lifetime)

BMI eligibility threshold>= 25 (>= 23 if self-identified as Asian)

Minimum weight loss for maintenance eligibility5% BMI reduction from baseline

Weight loss target for extended incentive9% BMI reduction (core + ongoing)

Last review2023-09-05

Effective

Next review

Reimbursement criteria and benefit limits

General Reimbursement Prerequisites

Services must meet ALL of the following to qualify for reimbursement:

ALL of the following

Service is medically necessary as determined by Neighborhood (may be evaluated against NCD, LCD, Interqual, EOHHS recommendations, or Clinical Medical Policies)
Provider verifies member eligibility, coverage and authorization prior to rendering services
Refer to plan-specific Prior Authorization Reference page; contact Provider Services
Provider holds a contract with Neighborhood that permits Fee-For-Service reimbursement for MDPP services

Provider Recognition Requirements

Providers must meet ONE of the following recognitions to furnish MDPP services:

HCPCS codes and billing categories

MDPP session and performance HCPCS codes (CMS approved)HCPCSCovered

G9873	First MDPP core session attended by beneficiary under MDPP Expanded Model (EM)
G9874	Four total MDPP core sessions attended (months 1-6) under MDPP EM
G9875	Nine total MDPP core sessions attended (months 1-6) under MDPP EM
G9876	Two MDPP core maintenance sessions attended in months 7-9; beneficiary did not achieve >=5% WL (months 7-9)
G9877	Two MDPP core maintenance sessions attended in months 10-12; beneficiary did not achieve >=5% WL (months 10-12)
G9878	Two MDPP core maintenance sessions attended in months 7-9; beneficiary achieved >=5% WL (months 7-9)
G9879	Two MDPP core maintenance sessions attended in months 10-12; beneficiary achieved >=5% WL (months 10-12)
G9880	One-time payment: beneficiary achieved at least 5% WL from baseline in months 1-12 (first achievement)
G9881	One-time payment: beneficiary achieved at least 9% WL from baseline in months 1-24 (first achievement)
G9882	Two MDPP ongoing maintenance sessions attended in months 13-15; beneficiary maintained >=5% WL

1–10 of 15

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Documentation, billing and submission requirements

Documentation Required

Maintain treatment record with required elements

Create and maintain a treatment record for each member receiving MDPP services. Records must be accurate, legible, and signed within 30 days of service.

Member identification (Neighborhood ID, name)
Documentation of medical necessity
Type of session (core/core maintenance/ongoing maintenance)
Coach leading the session (coach name)
Date and place of service
Recording of member's weight at each session

Prior Authorization

Verify eligibility and authorization prior to service

Verify member eligibility, coverage and authorization prior to rendering services. Refer to Neighborhood's plan-specific Prior Authorization Reference page for details and contact Provider Services for questions.

Key terms

Definitions

MDPPMedicare Diabetes Prevention Program

Core SessionsSessions furnished during months 1-6; approximately 1 hour; CDC-approved DPP curriculum

Core Maintenance SessionsSessions furnished during months 7-12; approximately 1 hour; CDC-approved DPP curriculum

Ongoing Maintenance SessionsSessions furnished during months 13-24; approximately 1 hour; CDC-approved DPP curriculum

Clinical and measurement thresholds

Eligibility & performance thresholds

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

Hemoglobin A1c range5.7% - 6.4% (within 12 months prior to first core session)

Fasting plasma glucose range110 - 125 mg/dL (within 12 months prior to first core session)

2-hour OGTT range140 - 199 mg/dL (oral glucose tolerance test; within 12 months prior to first core session)

Minimum weight loss for ongoing maintenance>= 5% BMI reduction from baseline and maintained for duration of ongoing maintenance sessions

Performance incentives5% BMI reduction during Core Sessions (one-time payment when first achieved in months 1-12); 9% reduction across core and ongoing sessions (one-time payment when first achieved in months 1-24). Incentive billed as second claim line for sessions where weight loss is maintained.

Document changes

04/01/2018policy_created

04/01/2018 Policy Created

05/25/2021format_updated

05/25/2021 Policy Review. Format Updated. No Content Changes.

10/01/2022annual_review

10/01/2022 Annual Policy Review Date. No Content Changes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDiabetes Prevention Program Payment Policy – Archive 4

Policy CodePolicy N/A

Change TypeAnnual review / formatting updates

Effective Date

Next Review Date

Key ActionVerify member eligibility, coverage and authorization prior to rendering MDPP services and maintain required treatment records including weights and session details.

SourceLink

On This Page

ANY of the following

MDPP Interim Preliminary Recognition
MDPP Preliminary Recognition
CDC Preliminary Recognition
CDC Full Recognition

Member Eligibility for MDPP Core Sessions

Members must meet ALL of the following on the date of the first core session:

ALL of the following

Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian)>= 25 (>= 23 if Asian)
On date of first core session
ONE of three blood test requirements within 12 months prior to first core session
- Hemoglobin A1c value between 5.7% and 6.4%5.7% - 6.4%
  Measured within 12 months prior to first core session
- Fasting plasma glucose of 110-125 mg/dL110 - 125 mg/dL
  Measured within 12 months prior to first core session
- 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)140 - 199 mg/dL
  Measured within 12 months prior to first core session
No previous diagnosis of diabetes prior to date of first core session (gestational diabetes exception allowed)

MDPP Ongoing Maintenance Sessions Eligibility

To qualify for ongoing maintenance sessions, the member must meet ALL of the following:

ALL of the following

Achievement of 5% minimum BMI reduction, based on initial session weight>= 5% BMI reduction from baseline
Measured from recorded weight at first core session
Maintenance of 5% BMI reduction for duration of Ongoing Maintenance sessionsMaintain >= 5% BMI reduction
Required for ongoing maintenance coverage

Benefit Limitations and Exclusions

MDPP coverage is subject to the following constraints:

ALL of the following

Services NOT covered for members with any of the following
- Members with a diagnosis of diabetes prior to the start date of the first core session
- Members with a diagnosis of End Stage Renal Disease (ESRD)
- Members not covered by INTEGRITY
- Members who have previously received MDPP services

Refer to the Prior Authorization Reference page for plan-specific requirements
Contact Provider Services at 1-800-963-1001 with questions

Billing Rule

Claim submission and form requirements

Submit claims on a CMS-1500 Professional claim form or electronically via X12 837P within contractually determined timely filing guidelines. Coding must meet CMS/CPT/HCPCS/ICD-10-CM standards and adjustments/corrections must include required forms.

Use CMS-1500 or electronic X12 837P format for claim submission
Submit within contractual timely filing guidelines
Follow CPT, HCPCS, and ICD-10-CM coding standards

Billing Rule

Make-up sessions modifier

Make-up sessions may be billed using modifier 'VM' in accordance with CMS guidelines.

Apply modifier VM for billed make-up sessions per CMS guidance

Billing Rule

Performance incentive billing

Performance incentive payments (G9880, G9881) are billed as a second claim line with the sessions for each session the member maintains the weight loss. BMI reduction is measured from the recorded weight at the first core session.

Incentive codes: G9880, G9881
Bill incentives as a second claim line with the session line
Measure BMI reduction from the weight recorded at the first core session

Documentation Required

Provide records upon request

Neighborhood may request medical records for any billed service. Documentation must support billed services and medical necessity and must comply with CMS standards and state/federal regulations.

Neighborhood may request copies of patient records at any time
Records must follow CMS documentation standards and state/federal regulations

09/05/2023annual_reviewLatest

09/05/2023 Annual Policy Review Date. No Content Changes.