May 30, 2019
Medicare Diabetes Prevention Program: Valid Claims
Note: This article was previously published in the May 23, 2019, edition of the CMS MLN Connects®![]()
For a claim to be valid under the Medicare Diabetes Prevention Program (MDPP), you must have both:
- Centers for Disease Control and Prevention (CDC) preliminary or full recognition; see the Supplier Fact Sheet
and CDC website for more information - Separate Medicare enrollment as an MDPP supplier (Specialty D1); see the Enrollment Fact Sheet
and Checklist
Important:
If you do not have a separate Medicare enrollment as an MDPP supplier and you submit a claim for MDPP services, your claim will be rejected.
Medicare enrolled MDPP suppliers: See the Quick Reference Guide to Payment and Billing
and the Billing and Claims Fact Sheet
for information on valid claims:
- MDPP Medicare beneficiary eligibility data is returned via the HIPAA Eligibility Transaction System (HETS)
on the 271 response; use this data to determine if a beneficiary meets the criteria to receive MDPP services - Submit claims when a performance goal is met, and report codes only once per eligible beneficiary (except G9890 and G9891)
- List each HCPCS code with the corresponding session date of service and the coach's National Provider Identifier (NPI)
- List all HCPCS codes associated with a performance payment (including non-payable codes) on the same claim
- Include Demo code 82 in block 19 (Loop 2300 segment REF01 (P4) and segment REF02 (82)) to identify MDPP services
- Do not include codes for other, non-MDPP services on the same claim
Trouble with MDPP billing and claims:
- Some MDPP claims are being denied as a result of a systems issue
- Medicare Administrative Contractors (MACs) are manually processing these claims through October 2019 until the fix is implemented
- Contact your MAC
with questions
For More Information:
- MDPP Expanded Model
Booklet - MDPP
webpage

