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Create a New Provider Type for CDC-Recognized Organizations

 
States can create a new provider type for organizations to enroll in Medicaid and deliver the National DPP lifestyle change program. Creating a new provider type gives states the advantage of having a group of providers who may be experienced and specifically focused on delivering the National DPP lifestyle change program. It can also allow states to track and evaluate the use of the benefit. Among states that have pursued this option, the CDC-recognized organization is enrolled as the new provider type (not the individual lifestyle coach). California, Maryland, New York, and Pennsylvania have all created a new provider type for CDC-recognized organizations, however, the Medicaid coverage mechanism varies for these states. To learn about each state’s approach, visit the State Stories of Medicaid Coverage page of the Coverage Toolkit.

Once Medicaid has decided to create a new provider type, it is not unusual for the process to take 6-12 months. There are several reasons why the process can take many months. First, creating a new provider type often means the Medicaid agency is establishing and covering a new service, which can entail a lengthy administrative process. Second, multiple priorities and pre-existing program queues can extend the timeline, as creating a new provider type is one of many program changes competing for time and resources within Medicaid. Third, creating a new provider type entails a substantial amount of coordination both within and beyond the Medicaid agency. Medicaid agencies may have to coordinate internally and externally, including with reimbursement, coverage, and IT divisions. Medicaid will likely also coordinate with the legislature and other external partners, including the public health department and health care provider associations (who may be involved to engage health care providers around the new provider type and service). Finally, Medicaid agencies do not necessarily create new provider types regularly and unfamiliarity with the process can add extra time.

Medicaid Communication to CDC-Recognized Organizations

Communication to CDC-recognized organizations that Medicaid has created a new provider type is an important step in implementation. For example, Maryland Medicaid created a new provider type and explained through a webinar the process for how CDC-recognized organizations enroll in Maryland’s electronic Provider Revalidation and Enrollment (ePREP) portal. Maryland Medicaid provides access to webinars (both upcoming and recordings), the ePREP link, and other documents related to Medicaid coverage of the National DPP lifestyle change program through this website.

Similarly, California created a website, delivered a webinar, and provided a FAQ document to communicate to CDC-recognized organizations how to enroll in Medi-Cal.

Pennsylvania Medicaid began its process of communicating the creation of a new Medicaid provider type to CDC-recognized organizations through a Medicaid bulletin to inform CDC-recognized organizations how to enroll in Medicaid. In conjunction with the bulletin, Pennsylvania surveyed all CDC-recognized organizations in the state to assess the organizations’ knowledge of the new provider type and to understand what type of technical assistance would be most valuable for the state to provide regarding enrolling in Medicaid and delivering the National DPP lifestyle change program to Medicaid beneficiaries.


The following paragraphs provide additional details about the steps in the above graphic.

 

Medicaid Creates New Provider Type Within MMIS

Another reason the process can take many months is that the new provider type must be entered into the Medicaid Management Information System (MMIS). Although programming a new provider type into a computer system may seem straightforward, for any provider type Medicaid must be able to enroll, reimburse, capture data, submit reports, and track new providers. Moreover, regardless of the age of the MMIS system, creating a new provider type is often a manual process. For example, the provider type values may be referenced in many places throughout the system, and it takes time to reprogram when a change is made. Additionally, testing must be scheduled and executed, and defects addressed.

Once a new provider type is created within the MMIS and Medicaid is ready to enroll new Medicaid providers, it may be advisable to create resources and training opportunities for new providers. For example, Maryland has created a website for new providers to support enrollment in their electronic Provider Revalidation and Enrollment Portal (ePREP).

 

Medicaid Determines Billing Codes for National DPP Lifestyle Change Program Services

To reimburse providers, Medicaid must identify or develop billing codes for the National DPP lifestyle change program sessions. The National DPP-specific CPT codes (0403T and 0488T) are intended to be used by CDC-recognized organizations that provide National DPP lifestyle change program services. For more information, please see the Coding and Billing page of the Coverage Toolkit.

 

CDC-Recognized Organizations Apply to Become Medicaid Enrolled Providers

To enroll in Medicaid, CDC-recognized organizations must submit appropriate documentation. Exact requirements may vary among Medicaid agencies and may include: submission of an application to Medicaid, proof of general liability insurance for the organization’s administrative location, proof of workers’ compensation insurance, proof of CDC recognition, and an Organizational National Provider Identifier (NPI). An NPI is a unique identification number that is needed to submit claims.

 

Medicaid Conducts High-Risk Screening of CDC-Recognized Organizations

The Centers for Medicare & Medicaid Services (CMS) screens newly enrolling Medicare Diabetes Prevention Program (MDPP) providers as a high categorical risk for fraud and abuse. MDPP suppliers must comply with high-risk requirements including background checks and fingerprinting for individuals with 5% or more ownership of the organization, and site visits. Because Medicare categorizes National DPP lifestyle change program providers as high risk, per interpretation of the rule below, Medicaid follows that risk status and conducts high-risk screening of CDC recognized organizations.

For more information about high risk status, please see the February 2, 2011 final rule on provider screening entitled, Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers.

 

If Using Online Providers, Medicaid Determines Site Visits

If the program is delivered online, through distance learning, and/or through a combination approach and the CDC-recognized organization’s administrative offices are located in a different state than the Medicaid agency covering the benefit, the Medicaid agency must determine what type of site visit it will accept to comply with CMS’ classification of a high-risk provider. State Medicaid agencies may consider various options for site visits. Medicaid agencies might require an in-person site visit which would require the CDC-recognized organization’s administrative office to be located in-state. Medicaid agencies may be able to accept a virtual site visit of the online, distance learning and/or combination provider. And finally, a Medicaid agency may be able to accept a site visit conducted by a different state’s Medicaid agency.

 

Managed Care: CDC-Recognized Organization Enrolls with MCOs and Completes MCO Credentialing Process

Many state Medicaid agencies contract with Medicaid managed care organizations (MCOs). In a managed care environment, the Medicaid agency contracts with and pays MCOs a capitated rate to deliver Medicaid covered services to beneficiaries. In these states, the CDC-recognized organization will obtain an Organizational NPI and enroll with the state Medicaid agency. Next, the CDC-recognized organization will likely enroll in one or more MCO networks and complete each MCO’s credentialing process.

Some MCOs are pursuing a delegated credentialing process for lifestyle coaches. With delegated credentialing, the MCO is responsible for credentialing the CDC-recognized organization yet is not responsible for credentialing the individual lifestyle coaches (see section below). For more information on MCOs, please see the Medicaid MCOs page.

 

CDC-Recognized Organization Ensures Lifestyle Coaches Meet Requirements

Lifestyle coaches facilitate the National DPP lifestyle change program sessions. When a CDC-recognized organization becomes a Medicaid enrolled provider, the individual lifestyle coaches may not have to enroll with Medicaid. Instead, the CDC-recognized organization may be responsible for ensuring the lifestyle coaches have an individual NPI and are trained and qualified to facilitate the National DPP lifestyle change program. As the Medicaid-enrolled provider, the CDC-recognized organization may then need to provide updated rosters of its lifestyle coaches to Medicaid.

 
 

Content Last Updated: June 11, 2020