Determining the Medicaid Enrolled Provider Type

 

Who Will Provide National DPP Lifestyle Change Program Services?

State Medicaid agencies must decide who will deliver the National Diabetes Prevention Program (National DPP) lifestyle change program to Medicaid beneficiaries. States have two options: they can use an existing provider type to deliver the program or they can create a new provider type. It is possible for states to pursue both options at the same time or to pursue one approach first and another approach at a later date. See the graphic below to learn more about using an existing provider type or creating a new provider type.

Rendering vs. Billing Providers
National DPP lifestyle change program Medicaid provider enrollment rules vary by state. Some states require both Medicaid billing and rendering providers for the National DPP lifestyle change program. Billing providers are reimbursed by Medicaid and rendering providers facilitate the National DPP lifestyle change program sessions. For example:

  • The billing provider could be the CDC-recognized organization and the rendering provider could be the lifestyle coach.
  • The billing provider could be a health system (health clinic or hospital) and the rendering provider could be a CDC-recognized organization.
  • The billing provider could be a physician or health system and the rendering provider could be a community health worker, lifestyle coach, or other non-licensed personnel trained to facilitate National DPP lifestyle change program curriculum.

In many states, both the billing and rendering provider will need a National Provider Identifier (NPI). However, some states may only require the CDC-recognized organization or facility to formally enroll in Medicaid and obtain an NPI. While the CDC-recognized organization will need to attest that their lifestyle coaches are in good standing with federal and state rules regarding license, certification, or training requirements, individual-level NPIs may not be required.

Billing and rendering providers can also be the same entity. An example of this would be a physician, advanced practice registered nurse (APRN), or another practitioner who is eligible to bill and render Medicaid services and is a trained National DPP lifestyle coach.

Delivery Options
Whether Medicaid is using an existing provider type or creating a new provider type, the Medicaid agency will have to determine the mode of delivery for the National DPP lifestyle change program: in-person, online, distance learning, and/or combination.

Click a button below to learn more about using an existing provider type or creating a new provider type.

 


 

Content last updated: April 16, 2020