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Provider Notice issued 08/05/2024

 

To:
All Medical Assistance Program Providers          
​Date August 5, 2024
​Re:
Fee-for-Service Claim Submittal for Diabetes Prevention and Management Programs 

This notice informs diabetes prevention and management programs that the Department of Healthcare and Family Services (HFS) has completed system modifications and programs may now submit fee-for-service claims. These programs are available to customers covered under Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care organization (MCO) plans.

As announced in informational notices dated August 20, 2021, and July 29, 2022, these programs are available to customers covered under Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care organizations (MCOs). Programs must be enrolled in HFS’ IMPACT system. HFS will provide reimbursement related to two nationally recognized programs described below:

·Diabetes Prevention Program (DPP)

The National Diabetes Prevention Program (DPP) is a yearlong, evidence-based lifestyle change intervention developed by the Centers for Disease Control and Prevention (CDC) to reduce the risk of adults with prediabetes progressing to Type 2 diabetes. The program achieves that goal primarily through weight loss that results from the CDC’s Diabetes Prevention Lifestyle Change curriculum, which focuses on healthy eating, increasing physical activity, and managing stress. CDC-recognized DPP organizations may enroll as an Illinois Medicaid provider to administer the program to deliver a set of medically necessary services to prevent or delay the onset of Type 2 diabetes for beneficiaries with indications of prediabetes. DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.

·Diabetes Self-Management Education and Support (DSMES)

Diabetes Self-Management Education and Support (DSMES) services are provided to prevent diabetes or the progression of diabetes, prolong life, and/or promote the physical and mental health of the beneficiary.

Services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill, and ability necessary for diabetes self-care; and nutritional counseling services.

Eligible customers may receive up to 18 hours of DSMES services during each 12-month period beginning with the initial training date, including:

 

·Up to three hours of individual DSMES, and

·Up to fifteen hours of group DSMES

 

Both types of diabetes prevention and management services will be billable via the X12 837P transaction or the MEDI Internet electronic claim system. Billing guidance has been published on the Non-Institutional Provider webpage. A fee schedule has been published on the Medicaid Reimbursement webpage.

A systematic timely filing override is in place for 180 days from the date of this notice that will allow currently enrolled providers to submit claims they may have held pending HFS billing system modifications.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for the FFS program, or the applicable HCI MCO.

 

 

Kelly Cunningham, Administrator 
Division of Medical Programs