NDPP Policy and Billing Guidelines

  • Guidelines also available in Portable Document Format

Medicaid National Diabetes Prevention Program

Last Revised 3/12/2020
Policy Changes are indicated with a ** in the Heading Name

This article is to notify Medicaid Fee–for–Service (FFS) providers and Medicaid Managed Care (MMC) Plans that federal approval has been granted to cover diabetes prevention services as outlined in the Centers for Disease Control and Prevention (CDC)–recognized National Diabetes Prevention Program (NDPP). The following program information pertains only to those CDC–recognized Hospital Outpatient Departments (OPDs), freestanding Diagnostic and Treatment Centers (D&TCs), Federally Qualified Health Centers (FQHCs), provider group practices, individual practitioners, community–based organizations (CBOs), and any out–of–state practitioners (hereinafter "Organization") that intend to enroll, provide, and bill Medicaid for NDPP educational and support services. Reimbursement for NDPP services will be available for both Medicaid FFS and MMC claims submitted for dates of service on or after February 1, 2020.

Lines of Business Eligible to Offer NDPP

Providers with members in the following lines of business are eligible to receive reimbursement for Medicaid NDPP services: Medicaid FFS, Mainstream MMC, HIV Special Needs Plans (HIV SNP), and Health and Recovery Plans (HARP).

Medicaid FFS NDPP Overview

The NDPP is an evidence–based, lifestyle change program designed to assist individuals diagnosed with prediabetes to prevent or delay the onset of type 2 diabetes. NDPP services are provided by trained Lifestyle Coaches who use a curriculum approved by the CDC. The NDPP focuses on providing members with a practical understanding of the positive impacts of healthier, sustained dietary habits; increased physical activity; and behavior change strategies for weight control.

CDC–Recognition Requirement

Organizations that would like to offer and be reimbursed by Medicaid for the NDPP lifestyle change program must first achieve recognition from the CDC based on its current National Diabetes Prevention Recognition Program (DPRP) Standards and Operating Procedures. There are three stages to CDC recognition: pending recognition, preliminary recognition, and full recognition. New York State (NYS) Medicaid recognizes all three CDC–recognition levels and will enroll any Organization that has achieved any of these recognition levels as a Medicaid NDPP service provider.

  • Before applying for CDC–DPRP recognition, the applying organization or provider should review the current DPRP Standards and Operating Procedures that describe the process of achieving and maintaining CDC–DPRP recognition. The current March 2018 DPRP Standards and Operating Procedures are located here.
  • The DPRP Standards and Operating Procedures also contain a capacity assessment. This is a list of questions designed to help an organization determine its capability and readiness to deliver the CDC–recognized lifestyle change program. All Organizations are strongly encouraged to complete the assessment located here.
  • Organizations that would like to apply for CDC recognition may complete the online application here.
  • The national registry of all CDC–recognized NDPPs is located here.

Note: An Organization´s enrollment in NYS Medicaid as an NDPP service provider is contingent upon their CDC–DPRP recognition status. Organizations are required to comply with the March 2018 DPRP Standards and Operating Procedures, or any subsequent/updated version published by the CDC. If an Organization fails to maintain a current, active CDC–DPRP recognition, it will lose its ability to seek reimbursement from Medicaid for NDPP services. If the Organization is only enrolled in Medicaid for the purpose of rendering NDPP services, then the Organization will be terminated as a Medicaid FFS provider, and pursuant to Section 5005(b)(2) of the 21st Century Cures Act and Section 1932(d) of the Social Security Act, it will also be removed from all MMC networks in which it participates. The Organization is required to notify the Medicaid program within 30 days if the Organization loses or changes its CDC–DPRP recognition at any time.

NDPP FFS Referral Requirement

Pursuant to the Medicaid approved State Plan Amendment (SPA), NDPP services are provided as preventive services in accordance with 42 CFR Section 440.130(c), and services must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice. Members are required to provide a referral to the NDPP service provider to be eligible to participate in the Medicaid NDPP. The referral must be maintained by the Medicaid–enrolled NDPP service provider.

CDC Program Eligibility Requirements

Medicaid members are eligible for NDPP services if they meet the following eligibility criteria set forth by the CDC in the DPRP Standards and Operating Procedures. The current March 2018 DPRP Standards are located here.

Note: Pursuant to the CDC–DPRP Standards and Operating Procedures, a minimum of 35% of all program participants who participate in the NDPP yearlong cohort must be eligible for the lifestyle change program based on either a blood test indicating prediabetes or a history of GDM. The remaining 65% of the program participants may be eligible based on the CDC Prediabetes Screening Test or the American Diabetes Association (ADA) Type 2 Diabetes Risk Test.

The Medicaid enrolled NDPP service provider must ensure that it receives and maintains the following documentation from the Medicaid member to verify NDPP eligibility:

  • The member´s referral to participate in NDPP services written by a physician, physician assistant (PA), nurse practitioner, or midwife. The referral should include the information of the member being referred to the NDPP; the information of the referring practitioner (name, address, National Provider Identifier (NPI)), and the information of the NDPP service provider the member is being referred to; and
  • A copy of the member´s blood test results within the past 12 months that indicate a diagnosis of prediabetes (required for at least 35% of program participants); or
  • A copy of the member´s blood test results within the past 12 months that indicate a normal postpartum A1C or glucose level and a GDM diagnosis during a previous pregnancy; or
  • A copy of the member´s positive prediabetes screening results the member received from the CDC´s Prediabetes Screening Test, or a screening result indicating high risk for type 2 diabetes based on the American Diabetes Association Type 2 Diabetes Risk Test at the addresses referenced above in this section (required for program participants that do not provide blood test results within the past 12 months that indicate a diagnosis of prediabetes).

Medicaid FFS Member Eligibility Requirements

The NDPP service provider must verify that the member has active Medicaid coverage prior to rendering NDPP services. The member´s eligibility must be verified for each date of service. A provider not verifying eligibility prior to the provision of services will risk the possibility of non–payment for those services. The Medicaid Eligibility Verification System (MEVS) manual is located at https://www.emedny.org/ProviderManuals/5010/MEVS/MEVS_DVS_Provider_Manual_(5010).pdf.

Medicaid FFS NDPP Structure

  • Allows for all CDC–DPRP (Pending, Preliminary, and Full) recognitions;
  • Does not limit NDPP services to once per lifetime;
  • Consists of only in–person group sessions;
  • Requires missed NDPP sessions be made up in–person only, either before or after a regularly scheduled NDPP session (allowed one time per–week), or on a different date of service within the same week;
  • Requires sessions be taught using a CDC–approved curriculum;
  • Requires sessions be taught by trained Lifestyle Coaches;
  • Requires sessions be approximately one–hour in length; and
  • Requires sessions include recording of the member´s body weight.

NDPP Delivery Mode: In Person

The Medicaid NDPP consists only of in–person, group sessions where members are required to be physically present in a classroom or classroom–like setting. The "Delivery Mode" referenced on the CDC–DPRP recognition letter awarding Pending, Preliminary, or Full recognition must reference a "Delivery Mode" of "In–Person." If the CDC recognition states a delivery mode of "Combination," additional documentation will need to be provided upon an Organization’s Medicaid enrollment indicating that an "In–person" delivery modality is part of its "Combination" CDC–recognition. NDPP Delivery modes of "Online" and "Distance Learning" are not acceptable NYS Medicaid NDPP "Delivery Modes." NDPP provider enrollment applications will be withdrawn from consideration if they lack the required "In–Person" "Delivery Mode" requirement.

NDPP Curriculum Requirements

Medicaid NDPP service providers must use an approved curriculum that meets the CDC requirements. Any NDPP curricula must be submitted, reviewed, and approved by CDC prior to its use.

All curricula used for CDC–recognized lifestyle change programs must be backed by science and:

  • Emphasize the overarching goal of preventing type 2 diabetes;
  • Focus on making lasting lifestyle changes, rather than simply completing the curriculum;
  • Build up to moderate changes in diet and physical activity;
  • Discuss strategies for self–monitoring of diet and physical activity, building participant self–efficacy and social support to maintain lifestyle changes and problem–solving to overcome common weight loss, physical activity, and healthy eating challenges;
  • Document participants´ weight and physical activity minutes at each session; and
  • Provide participant materials to support program goals.

The CDC–developed PreventT2 curriculum is freely available for use and can be found here. Organizations may also use other curricula that have been approved by CDC as meeting the standards. Learn more about curriculum requirements in the CDC Standards and Operating Procedures located here.

NDPP FFS Provider Enrollment and Billing Guidance

An Organization must first comply with the DPRP Standards and Operating Procedures set forth by the CDC as outlined in the DPRP, and must obtain a valid, current pending, preliminary, or full NDPP recognition. Organizations looking to enroll and bill Medicaid as an NDPP service provider must first become recognized by the CDC prior to engaging in their Medicaid NDPP provider enrollment application process.

All Practitioner Group Practices, Hospital OPDs, D&TCs, FQHCs and CBOs that are currently enrolled in NYS Medicaid under an existing NPI, Category of Service (COS), and/or specialty code are required to obtain and enroll a new, separate, and distinct NPI to be used solely for the purpose of enrolling in Medicaid as an NDPP service provider. The newly acquired NDPP NPI will be enrolled in the Medicaid program under the new CBO COS of 0572 and will be identified as a CBO solely for purposes of NDPP provider enrollment and claims payment. This identification does not affect or impact any other aspects of their Medicaid provider enrollment file. Once enrolled in Medicaid as an NDPP service provider, claims may be submitted to Medicaid for NDPP services rendered to Medicaid members. Providers that are required to obtain a new NPI as part of this process may do so at any time through the National Plan and Provider Enumeration System (NPPES) website located at https://nppes.cms.hhs.gov/#/.

Individual practitioners (Physicians, Nurse Practitioners, Midwives) that are already enrolled in Medicaid under an existing NPI may utilize the same NPI for NDPP enrollment purposes.

  1. Community Based Organizations (CBOs):
    All CBOs are required to obtain and enroll under a new NPI for the purposes of enrolling in Medicaid as an NDPP service provider. This requirement applies even if the CBO is currently enrolled in Medicaid under an already existing NPI, COS, and/or specialty code. They are still required to obtain a new, unique NPI for the purposes of enrolling in Medicaid as an NDPP service provider.

    Once the CBO has obtained its new NDPP NPI and has also achieved either Pending, Preliminary, or Full recognition from the CDC, it may move forward with applying to enroll in NYS Medicaid as an NDPP service provider.

  2. The CBO would go to the "CBO Enrollment Forms & Instructions" section of the eMedNY NDPP provider enrollment page located here for additional information pertaining to NDPP enrollment instructions, requirements, and other important information about participating in the NYS Medicaid program as an NDPP service provider.

    Newly enrolling CBOs should complete and submit the following NYS Medicaid enrollment forms, along with the documentation received from the CDC stating that they have achieved DPRP recognition: CBOs must also complete the following "NYS Medicaid Business Disclosure Form" any time they revalidate their Medicaid enrollment, or anytime a new Lifestyle Coach is added to their Organization. All of the above referenced documents are also available on the "CBO Enrollment Forms & Instructions" link referenced above. Providers should also be sure to thoroughly review the "Requirements & Additional Forms" section of the eMedNY NDPP CBO provider enrollment page to ensure that they have reviewed, completed, and submitted all of the required Medicaid enrollment or maintenance transaction forms. Failure to provide the requested information will result in the application being deemed incomplete and returned to the provider unprocessed.

    Once the completed application has been reviewed and approved, the newly created CBO COS of 0572, and the NDPP specialty code of 105 will be assigned to the CBO´s provider enrollment file. The assignment of the NDPP specialty code is a required component for Medicaid reimbursement of NDPP services.

    COS 0572 was established to identify the newly created CBO provider type within the Medicaid program. COS 0572 cannot be added to an existing NYS Medicaid provider enrollment file. An organization´s enrollment in Medicaid under COS 0572 is a separate and distinct Medicaid enrollment and will not affect any aspect of an Organization´s other Medicaid enrollment file(s). CBO´s enrolled in Medicaid under COS 0572 may only be assigned specialty codes to render specific services as designated by the Department of Health (DOH). At this time, NDPP services under specialty code 105 is the only specialty code/service that has been approved by DOH to be rendered under COS 0572.
  3. Individual Practitioner Practices
    Individual practitioners are required to obtain an NPI for the purpose of enrolling in Medicaid as an NDPP service provider. If the practitioner is already enrolled in NYS Medicaid under an existing NPI, COS, and/or specialty code, then that same NPI may be utilized for NDPP enrollment purposes. In that situation, the new NDPP 105 specialty code will be assigned to the practitioner´s existing provider enrollment file.

    Once the practitioner has an NPI and has also achieved either Pending, Preliminary, or Full recognition from the CDC, the practitioner may move forward with applying to enroll in NYS Medicaid as an NDPP service provider.

    The practitioner would go to the "Individual Practitioners (Physicians, Nurse Practitioners, Midwives)" section of the eMedNY NDPP provider enrollment page located https://www.emedny.org/info/ProviderEnrollment/NDPP/index.aspx, and click on the link for the applicable Medicaid provider type for additional enrollment instructions, requirements, and other important information about participating in the NYS Medicaid program as an NDPP service provider

    Newly enrolling Individual Practitioners should complete and submit the following NYS Medicaid enrollment forms along with the documentation received from the CDC stating that they have achieved DPRP recognition:
    • ➢ NDPP Recognition Attestation (eMedNY–434901); and
    • ➢ NYS Medicaid Practitioner enrollment form (EMEDNY–436801); or
    • ➢ NYS Medicaid Ordering, Prescribing, Referring, Attending, (OPRA) enrollment form (EMEDNY–436901) if the practitioner is looking to only enroll and participate in Medicaid as a Managed Care provider.
    Individual practitioners who are already enrolled in Medicaid under an existing NPI, COS, and/or specialty code and are looking to add the NDPP specialty code should complete and submit the following NYS Medicaid maintenance forms along with the documentation received from the CDC stating that they have achieved DPRP recognition: Individual practitioners must complete and submit the above "NYS Medicaid Practitioners or Physicians Disclosure Form" any time they revalidate their Medicaid enrollment, or anytime a new Lifestyle Coach is added to the practice.

    All of the above–referenced documents are also available on the applicable Medicaid provider type link located on the eMedNY NDPP provider enrollment page referenced above. Practitioners should also thoroughly review the "Requirements & Additional Forms" section of the eMedNY NDPP provider enrollment page to ensure that they have reviewed, completed, and submitted all required Medicaid enrollment or maintenance transaction forms. Failure to provide the requested information will result in the application being deemed incomplete and returned to the provider unprocessed.

    Once the completed application has been reviewed and approved, the practitioner will be assigned the newly created NDPP specialty code of 105 that will be added to their provider enrollment file, in addition to any other professional specialty codes and/or professional COS codes (i.e., 0460 for physician, 0469 for Nurse Practitioner, or 0525 for Midwife) that may be applicable to the practitioner at the time of enrollment. If the practitioner is already enrolled in NYS Medicaid under an existing NPI, COS, and/or specialty code, then the new NDPP 105 specialty code will be assigned to the practitioner´s existing provider enrollment file.
  4. Practitioner Group Practices
    All practitioner group practices are required to obtain and enroll under a new NPI for the purposes of enrolling in Medicaid as an NDPP service provider. This requirement applies even if the group practice is currently enrolled in Medicaid under an already existing NPI, COS, and/or specialty code. They are still required to obtain a new, unique NPI for the purposes of enrolling in Medicaid as an NDPP service provider.

    Once the group practice has acquired its new NDPP NPI, it will follow the same process referenced above under section "A – Community Based Organizations (CBOs)" for the purpose of enrolling in Medicaid as an NDPP service provider.

    The practitioner group practice will be enrolled in Medicaid as an NDPP service provider under its new NPI and will be identified as a CBO under COS 0572 . This identification does not affect or impact any other aspects of the practice´s Medicaid provider enrollment file. Once the practice has been enrolled in Medicaid as a CBO under COS 0572 and assigned the NDPP specialty code of 105, it may begin submitting claims to Medicaid for NDPP services rendered to Medicaid members.
  5. Clinics–Hospital OPDs, D&TCs, and FQHCs providing NDPP services:
    All Hospital OPDs, D&TCs, and FQHCs are required to obtain and enroll under a new NPI for the purpose of enrolling in Medicaid as an NDPP service provider. This requirement applies even if the Hospital OPD, D&TC, or FQHC is currently enrolled in Medicaid under an already existing NPI, COS, and/or specialty code. They are still required to obtain a new, unique NPI for the purpose of enrolling in Medicaid as an NDPP service provider.

    Once the Hospital OPD, D&TC, or FQHC has acquired its new NDPP NPI, it will follow the same process referenced above under section "A – Community Based Organizations (CBOs)" for the purpose of enrolling in Medicaid as an NDPP service provider.

    The clinic will be enrolled in Medicaid as an NDPP service provider under its new NPI and will be identified as a CBO under COS 0572. This identification does not affect or impact any other aspects of the clinic´s Medicaid provider enrollment file. Once the clinic has been enrolled in Medicaid as a CBO under COS 0575 and assigned the NDPP specialty code of 105, it may begin submitting claims to Medicaid for NDPP services rendered to Medicaid members.

    This organizational structure allows for the CDC–recognized Hospital OPD, D&TC, or FQHC clinics to be enrolled in NYS Medicaid as an NDPP service provider under a new NPI for the purpose of rendering these non–medical, group–based educational support services to Medicaid members in any service location within the community.
    • The Organizations are allowed to either utilize their existing infrastructure to offer NDPP classes on–site at their facility, or they may partner with a local CBO to leverage their position within the community to better reach and access Medicaid members where they live.
    • This construct provides a mutually beneficial, symbiotic opportunity for any CBOs that may want to offer NDPP services within their community to partner with a CDC–recognized, Medicaid–enrolled NDPP service provider and allow them to utilize their space to deliver NDPP services.
    • This will also allow for those clinics that enroll as NDPP service providers to partner with a local CBO to leverage the CBOs´ presence and proximity to the Medicaid members in the community to hold their NDPP group–based sessions.

      CBOs that would like to partner with a CDC–recognized organization may find a registry of the recognized organizations at https://nccd.cdc.gov/ddt_dprp/registry.aspx. Providers should use the "Show organizations by location" drop–down and chose New York to filter the registry to show the organizations that have already been recognized by the CDC in NYS.

NDPP Lifestyle Coaches

NDPP–recognized Organizations must use trained Lifestyle Coaches to provide NDPP services to Medicaid members. The role of the trained Lifestyle Coaches is to promote realistic lifestyle change, emphasize weight loss through healthy eating and physical activity, and implement the NDPP curriculum.

of the positive impacts of healthier, sustained dietary habits; increased physical activity; and behavior change strategies for weight control and will offer the following services with the goal to prevent Type 2 diabetes:

  • 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 to prevent the onset of Type 2 diabetes; and
  • Nutritional counseling.

Lifestyle Coaches are required to obtain and maintain a valid NPI at all times. The NPI is for claim reporting purposes only and Lifestyle Coaches will not be required to enroll in the Medicaid program. Lifestyle Coaches may be a physician, non–physician practitioner, or an unlicensed person who has been formally trained pursuant to a CDC–approved curriculum for a minimum of 12 hours, or approximately two days, by one of the following:

  • A training entity listed on the CDC website;
  • A private organization with a national network of CDC–recognized program sites;
  • A CDC–recognized virtual organization with national reach; or
  • A Master Trainer, as designated by the CDC–recognized program, who has delivered the lifestyle change program for at least one year and has completed a Master Trainer program offered by a training entity on the CDC website.

Entities that have been approved to provide formal training to a CDC–approved curriculum are listed on CDC´s website.

When completing the Medicaid provider enrollment forms referenced below, Organizations are required to disclose to Medicaid all of their trained Lifestyle Coaches that deliver NDPP services to Medicaid members as an employee/agent/contractor, on its behalf. The Lifestyle Coaches will undergo a background check performed by the Department of Health (DOH) to ensure program integrity, and to address the potential risk for fraud, waste, and abuse. The Medicaid–enrolled NDPP service provider is required provide the following information for each Lifestyle Coach who delivers NDPP services as an Employee/Agent/Contractor, on its behalf:
Name;
Association Type = (Employee/Agent);
Home Address (Street Address, City, State, Zip)
SSN; and
DOB.

  • CBOs that are newly enrolling are required to complete:
    The entire NYS Medicaid Business Enrollment Form (EMEDNY–436701) including Section five entitled "Agents, Managing Employees & Those with a Control Interest" for each Lifestyle Coach.
  • CBOs that are revalidating, or adding a new Lifestyle Coach are required to complete:
    The entire NYS Medicaid Business Disclosure Form (EMEDNY–380101).
  • Individual Practitioners that are newly enrolling are required to complete:
    The entire NYS Medicaid Practitioner enrollment form (EMEDNY–436801), or the entire NYS Medicaid Ordering, Prescribing, Referring, Attending (OPRA) enrollment form (EMEDNY–436901) including Section five entitled "Agents, Managing Employees & Those with a Control Interest."
  • Individual Practitioners that are already enrolled, revalidating or are adding a new Lifestyle Coach Required to Complete:
    The entire NYS Medicaid Practitioners or Physicians Disclosure Form (EMEDNY–380104).

Organizations are required to update their Medicaid NDPP provider enrollment file within 30 days whenever a new Lifestyle coach is added to the program. Failure to provide the requested information will result in the application being deemed incomplete and returned to the provider unprocessed. If the Organization is already enrolled as an NDPP service provider, its claims for NDPP services may not be reimbursed and/or the Organization´s enrollment in the Medicaid Program may be terminated.

All of the above referenced provider enrollment and maintenance forms are available on the eMedNY NDPP "Provider Enrollment & Maintenance" page located at https://www.emedny.org/info/ProviderEnrollment/NDPP/index.aspx. Providers should also be sure to thoroughly review the "Requirements & Additional Forms" section of the various eMedNY NDPP provider enrollment pages to ensure that they have reviewed, completed, and submitted all of the required Medicaid enrollment or maintenance transaction forms. Failure to provide the requested information will result in the application being deemed incomplete and returned to the provider unprocessed.

Note: A typed roster of all employed or contracted Lifestyle Coaches must be maintained by the Organization at all times. The NDPP Lifestyle Coach roster shall include each coach´s full name, NPI number, date of birth (DOB), and Social Security Number (SSN). The roster must also include an accurate change log stating all of the Lifestyle Coaches who have been added or removed from its NDPP.

NDPP FFS Procedure Codes

Claims for NDPP services must be submitted to Medicaid on a professional claim type form via the CMS–1500 paper claim form, or its electronic equivalent. Below are the procedure codes utilized to bill Medicaid for NDPP services.

  • 0403T – This is a $22.00 per–member, per–session reimbursement for members who attend in–person NDPP group counseling sessions.
  • G9880 – This is a $70.00 incentive payment that is awarded to providers for members who have achieved at least 5% weight loss from their baseline. This provider incentive payment is available only once to the provider over the course of the 22 sessions when the member first achieves the 5% weight loss from baseline. If the Medicaid member re–enrolls in a new Medicaid NDPP cohort at a later time, this incentive payment will be available again to the provider when the member achieves at least a 5% weight loss from the new baseline.

NDPP services are offered to eligible Medicaid members as preventive services under the approved Medicaid State Plan, and NDPP services are paid at 100% by the Medicaid program. Therefore, Medicaid cost–sharing rules do not apply to NDPP services.

Note: NDPP–enrolled service providers cannot bill Medicaid for any non–NDPP services on their NDPP claims. If a provider is enrolled in NYS Medicaid as an NDPP service provider and also under a different NPI, COS, and/or specialty code, then the provider must submit NDPP services and non–NDPP services on separate claim forms. These services cannot be combined on the same claim.

NDPP FFS Make–up Sessions Requirements

If a member misses an NDPP session, the Organizations may offer an in–person make–up session. Make–up sessions may be held on either the same date of service as a regularly scheduled NDPP class session, or on a date of service other than a regularly scheduled class session. Only one make–up session per week can be made up on the same date of service as a regularly scheduled NDPP class session. Claims submitted to Medicaid for NDPP make–up sessions that were held on the same date of service should be done in the following manner.

  • Submit the 0403T procedure code on one claim line and indicate two units for that date of service.

NDPP Billing FFS for Mixed Cohorts

Medicaid is always the payer of last resort. All claims for NDPP services should be submitted to a member´s primary insurance company prior to being submitted to Medicaid for reimbursement.

If the provider knows that the service will not be covered by a member´s primary insurance because of a previous denial for NDPP services, then the claim may be submitted directly to Medicaid for reimbursement with a zero–fill ($0.00) in the spot for the primary insurance company´s payment. The provider must:

  • Already have billed and received a denial from the member´s primary insurance company for a non–covered service; and
  • Maintain proof of the denial in the member´s billing record.

** NDPP FFS Service Location Requirements

Since the NYS Medicaid NDPP consists only of in–person group sessions, the Medicaid–enrolled NDPP service provider must have the capacity to deliver in–person group sessions, which are accessible to the member in a community setting location.

A community setting location must be one that:

  • Is open and accessible to the public;
  • Has a designated space in which to conduct the yearlong lifestyle change program;
  • Provides a private setting in which members can be weighed and monitored by a Lifestyle Coach; and
  • Is not a private residence.

Community settings may include, but are not limited to, church basements or multipurpose rooms in recreation centers, community centers, schools, campuses, etc. NDPP service providers may not list a private/home residence as service location for NDPP services on their NYS Medicaid enrollment application, revalidation or maintenance request. A personal residence is not an acceptable service location for NDPP services. All service locations must be disclosed on the appropriate eMedNY provider enrollment application, revalidation or maintenance request.

For CBOs, the service address(s) listed on page 3 of the NYS Medicaid Business Enrollment Form (EMEDNY–436701) cannot match any address(s) disclosed under Section 1 (Disclosing Entity / Applicant) on page 4 of the application, or any address(s) disclosed under Section 5 (Agents, Managing Employees & Those with a Control Interest) on pages 5–6 of the application.

The service address(es) reported on a NYS Medicaid application, revalidation or maintenance request will be evaluated at the time of processing to ensure they do not match any home address for any individual disclosed as an owner, agent, managing employee, Lifestyle Coach, or who has a controlling interest. If a service location address listed on the NYS Medicaid enrollment application, revalidation or maintenance form matches a home address, it will result in the application being returned to the provider unprocessed.

NDPP FFS Provider Enrollment Checklist

Below is a checklist Organizations may reference when submitting an application to NYS Medicaid for enrollment as an NDPP service provider.
Organizations must:

  • Currently have an active CDC–DPRP pending, preliminary, or full recognition status;
  • Obtain an NPI number for your organization;
  • Direct individual Lifestyle Coaches to obtain their own NPI number;
  • Go to https://www.emedny.org/info/providerenrollment/ndpp/index.aspx to review and complete all the required Medicaid NDPP provider enrollment forms, and review all other important information about participating in the NYS Medicaid program as an NDPP service provider;
  • Review and complete the required NDPP provider Attestation form (eMedNY form #434901);
  • Provide copies of any and all relevant documents/correspondence received from the CDC stating that the Organization has achieved CDC–DPRP recognition, which shall include the current/active recognition level achieved at the time of application, the recognition effective/end dates, and their approved delivery mode (in–person is required to become a Medicaid NDPP service provider). Provide this information along with any other required NYS Medicaid provider enrollment application or maintenance transaction forms;
  • Submit the completed, signed, and dated Medicaid provider enrollment application or provider maintenance transaction forms for review; and
  • Pay the Medicaid enrollment fee ($586).

Note: For a limited time, Medicaid will waive the initial NDPP enrollment application fee for all newly enrolling NDPP service provider applications. This application fee waiver is made available via a grant that was awarded to NYS by the CDC to support the establishment of new Diabetes Prevention Program delivery organizations and increase participation among high–burden populations. The waiver is only available for a limited time based on grant funding.

Organizations are required to update their Medicaid NDPP provider enrollment file within 30 days whenever a new Lifestyle coach is added to the program and/or a new/higher level of CDC–DPRP recognition has been achieved.

NDPP FFS Billing Checklist

Below is a checklist Organizations may reference when submitting claims to Medicaid for NDPP services. All NDPP claims must contain the following:

  • The Medicaid members Client Identification Number (CIN) and any other demographic information needed to submit the NDPP claim to Medicaid;
  • The billing provider NPI, which is the NPI of the Medicaid enrolled NDPP service provider;
  • The rendering provider NPI, which is the NPI of the trained Lifestyle Coach that rendered the NDPP service to the Medicaid member. If the claim is being submitted by a practitioner (Physician, Nurse Practitioner, or Midwife), and the practitioner also rendered the NDPP services to the Medicaid members, then the practitioner´s NPI would be submitted on the claim in both the billing and rendering provider NPI locations;
  • The valid diagnosis code (DX) code;
  • The valid NDPP procedure code; and
  • The valid date of service that the NDPP service was rendered to the member.

NDPP FFS Provider Responsibility Checklist:

Medicaid–enrolled NDPP service providers are required to comply with the following requirements which include, but are not limited to:

  • Ensuring all requirements for achieving and maintaining CDC–DPRP recognition have been met;
  • Screening and hiring NDPP Lifestyle Coaches;
  • Ensuring Lifestyle Coaches have been trained to a CDC–approved curriculum, and coordinating any ongoing training and skill–building that may be required or needed;
  • Screening participants for active Medicaid eligibility and that they meet the NDPP eligibility requirements;
  • Complying with all applicable laws, rules, and regulations pertaining to the NYS Medicaid program, including those governing participant privacy and data security (e.g., HIPAA);
  • Maintaining all records pertaining to CDC recognition, Medicaid enrollment, Medicaid claim–supporting documentation, and Lifestyle Coach rosters for the timeframe required to comply with the Medicaid program´s record–keeping requirements; and
  • Monitoring and evaluating the quality of support provided to program participants.

Medicaid FFS Transportation:

Medicaid transportation is a covered benefit for all eligible Medicaid members traveling to Medicaid–covered services. Coverage of the CDC–NDPP was added to the NYS Medicaid State Plan in September 2019 and is a NYS Medicaid–covered service.

NDPP Medicaid Managed Care (MMC) Guidance

MMC Plans must cover the NDPP benefit and make it available to eligible MMC members. This applies to MMC Plans, including Mainstream MMC, HIV Special Needs Plans (HIV SNP), and Health and Recovery Plans (HARP). MMC Plans must comply with the coverage requirements for the NDPP benefit as outlined in NYS Social Services Law, the monthly Medicaid Update, Provider Bulletins, and/or any Provider Manual updates.

  • Once an NDPP–recognized service provider is enrolled in Medicaid FFS, the Organization can also reach out to the MMC Plans to inquire about becoming part of their NDPP provider network.
  • MMC Plans are allowed to create a different payment structure, however; it is expected that Plans and providers will negotiate contracts with reasonable payment terms and conditions. If a MMC plan and provider cannot reach agreement on payment terms, the MMC plan will offer a rate equivalent to the Medicaid FFS payment.
  • A directory by MMC Plan can be found on the DOH´s website at: https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers_Managed_Care_Information.pdf
  • Any questions regarding specific MMC contracting, rates, reimbursement, etc. should be directed to the individual Plan(s) in which the provider contracts. A MMC directory by plan can be found on the Department´s website here.
  • The MMC Plans may also utilize the Network Provider Enrollment list located here to review and determine what Organizations have completed and pending applications to become a NDPP service provider with NYS Medicaid. This list will assist the MMC Plans in determining which NDPP Organizations to participate with in an effort to expand their network adequacy.

NDPP FFS Listserv

The eMedNY NDPP Listserv provides information relative to Medicaid´s coverage and reimbursement of the CDC´s NDPP for Medicaid FFS and MMC members.

How to Subscribe
Navigate to the "eMedNY Listserv" page located here, and scroll down to the National Diabetes Prevention Program (NDPP) on Listserv list, and click "Subscribe" to sign up for the NYS Medicaid NDPP Listserv.

Unsubscribe
Navigate to the "eMedNY Listserv" page located here, and scroll down to the National Diabetes Prevention Program (NDPP) on Listserv list, and click "Unsubscribe" to be removed from the NYS Medicaid NDPP Listserv.

NDPP FFS Statewide Trainings

On August 1, 2019, NYS was awarded a $100,000 Technical Assistance (TA) grant funded by CDC´s Division of Diabetes Translation to demonstrate how state Medicaid agencies can implement delivery models for the National DPP lifestyle change program for Medicaid beneficiaries at high risk for type 2 diabetes. The TA grant is managed by the National Association of Chronic Disease Directors (NACDD).

This project represents a collaboration between the NYS Department of Health´s Diabetes Program and the NYS Medicaid program to increase providers´ knowledge and awareness of the Medicaid program´s coverage and availability of the new NDPP evidence–based, educational and support program.

This will be accomplished through the development and delivery of four statewide diabetes prevention symposia that will be held in 2020 that will be designed to bring together current and potential Medicaid NDPP delivery organizations to inform them about becoming a NYS Medicaid NDPP service provider. The dates of the four statewide learning symposia will be announced at a later date through the NDPP Listserv. Additional information relative to the upcoming, 2020 NYS Medicaid NDPP symposia will be communicated via the eMedNY NDPP Listserv.

Medicaid FFS Provider Enrollment Training & Billing Assistance

  • The eMedNY call center is available via phone to assist Medicaid providers with provider enrollment, claim submission, and reimbursement questions at 800–343–9000.
  • eMedNY regional provider services representatives are available for in–person provider training and assistance throughout the state upon request. To request in–person training, please contact the eMedNY Call Center at the phone number referenced directly above.
  • Submit electronic transactions (claims submissions and member eligibility checks) to Medicaid free of charge via ePACES.
  • Provider training videos on various topics including ePaces, information for new providers/new billers, provider enrollment, and the Medicaid Eligibility Verification System (MEVS) are available to assist providers here.
  • eMedNY provides an "Introduction to Provider Enrollment" that walks providers through the steps of how to enroll as a provider of services for the NYS Medicaid program here.
  • eMedNY provides a step–by–step process on how to submit and be paid for services rendered to eligible Medicaid clients at the same link referenced in the bullet directly above.

Medicaid FFS Questions/Contact Information

For questions related to:

Providers seeking assistance with FFS NDPP claims reimbursement and/or provider enrollment;

  • Contact: Computer Sciences Corporation (CSC a/k/a CSRA) at 1–800–343–9000 or via email at emednycallctr@csra.com or visit eMedNY for additional information.

Providers seeking assistance with FFS NDPP policy;

  • Contact: Office of Health Insurance Programs at 518–473–2160 or via email at NDPP@health.ny.gov.

Providers seeking assistance with MMC NDPP claims reimbursement and/or provider contracting;

  • Contact: The specific MMC Plan in question. A directory by MMC Plan can be found on the DOH´s website here.