Medicaid → Implementation → Screening and Identification for Medicaid Agencies and MCOs

Screening and Identification for Medicaid Agencies and MCOs

 

States and their partners can identify prospective participants for the National Diabetes Prevention Program (National DPP) lifestyle change program based on participant eligibility criteria.

This page contains the following topics:

1. Eligibility Requirements for the National DPP
2. Participant Identification and Engagement Workflows (including HRSN)
3. Medical Claims or Electronic Health Records
4. Tracking Eligibility Through a Claims System
5. Identification by Providers
6. Health Information Exchange Engagement
7. HRSN Screening Tools

 

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Eligibility Requirements for the National DPP

To be eligible for referral to the National DPP lifestyle change program, individuals must meet the following requirements:

• All of a program’s participants must be 18 years of age or older. The program is intended for adults at high risk of developing type 2 diabetes.
• All of a program’s participants must have a body mass index (BMI) of ≥25 kg/m2 (≥23 kg/m2, if Asian American).
• All of a program’s participants must be considered eligible based on either:
  • A blood test result within one year of participant enrollment. Blood test results may be self-reported for CDC recognition purposes. Participants enrolled in the Medicare Diabetes Prevention Program (MDPP) cannot self-report blood test results; lab results must be provided. Blood test results must meet one of the following specifications:
  • Fasting glucose of 100 to 125 mg/dl (Centers for Medicare and Medicaid Services-CMS- eligibility requirement for MDPP participants is 110 to 125 mg/dl);
  • Plasma glucose of 140 to 199 mg/dl measured 2 hours after a 75 gm glucose load;
  • HbA1C of 5.7 to 6.4; or,
  • Clinically diagnosed gestational diabetes mellitus (GDM) during a previous pregnancy (allowed for CDC recognition and may be self-reported; not allowed for MDPP participants); or
  • A positive screening for prediabetes based on the Prediabetes Risk Test online. Note: The risk test is not an option for eligibility for MDPP participants.
• Participants cannot have a previous diagnosis of type 1 or type 2 diabetes prior to enrollment.
• Participants cannot be pregnant at time of enrollment.
• A health care professional may refer potential participants to the program, but a referral is not required for participation in a CDC-recognized program.

To be eligible for the National DPP lifestyle change program, individuals must have one of the blood test results described above, be previously diagnosed with gestational diabetes, or score positive for prediabetes on the CDC/ADA Prediabetes Risk Test. The CDC Diabetes Prevention Recognition Program (DPRP) standards require that at least 35% of a program’s participants be diagnosed with prediabetes through blood testing (or have a history of gestational diabetes). The remaining participants in the group can be considered eligible for the program based on their scores on the CDC/ADA Prediabetes Risk Test. The CDC/ADA Prediabetes Risk Test is a brief seven question survey that allows one to gauge their risk of having prediabetes. Regularly scheduled biometric screenings may be an opportunity to determine if an individual is eligible.
 

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Participant Identification and Engagement Workflows

A workflow is the series of activities that are necessary to complete a task, such as enrolling a participant in the National DPP lifestyle change program. Each step in a workflow has a specific step before it and a specific step after it, except for the first and last steps. Outlining National DPP engagement workflows helps partners to explore existing processes and processes that need to be developed for participant engagement. These may include establishing workflows for identification, referral, and outreach.

When developing a participant engagement workflow for the National DPP lifestyle change program, states should consider:

• What existing mechanisms are in place for identification, referral, outreach, and engagement;
• Which partners should be involved, their roles and responsibilities, and how they can help promote program success; and
• The timing and resources needed to establish connecting points between various process steps (e.g., engaging with potential participants before enrollment).

States should also consider other factors that can contribute to an individual’s ability to participate and be retained in the National DPP lifestyle change program, including the individual’s health-related social needs (HRSN). When considering strategies for HRSN screening, it is important to ensure that screening participants are informed as to how their responses will be used, and resources are available to address HRSN discovered through screening. People with identified HRSN should be referred to resources that address these needs as often as possible. This will require developing connections with local organizations and programs that address common HRSN. Coordinating and collaborating with partners across sectors, including state Medicaid agencies, Medicaid MCOs, health care providers, and community partners can improve efficiencies in addressing HRSN by engaging in strategic planning across teams and organizations. For example, MCOs can work with providers in their network to create standardized screening processes and support provider education on HRSN. Additionally, community partners conduct community health needs assessments (CHNAs) to learn more about the HRSN of the populations they are serving, and share this information with other organizations, including health care delivery organizations. The federal government requires a hospital organization to conduct a CHNA every three years and adopt an implementation strategy to meet the community health needs identified through CHNA. These existing assessments may serve as the focal point for partnerships. To learn more about the federal CHNA hospital requirement, you may visit this page. Partners should consider:

• Who conducts the HRSN screening;
• When the screening is conducted; and
• How participants are connected to HRSN resources.

While each workflow will be unique depending on the needs and priorities of the organizations involved, the Participant Identification and Engagement Workflow provides prompts to assist state partners in brainstorming and developing individual workflows related to participant identification, outreach, referral, engagement, and HRSN screening. Several examples of how states are developing National DPP workflows are also provided in the tab table below.

 

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Medical Claims or Electronic Health Records

States implementing the National DPP lifestyle change program have leveraged electronic health record (EHR) data and/or medical claims data to proactively identify individuals who are, or may be, eligible for the program. For instance:

• In the Medicaid Coverage for the National DPP Demonstration Project, Maryland used ICD-10 codes from claims data to identify individuals who fit the eligibility criteria. The codes flagged individuals who were overweight or obese, who had elevated glucose levels, or had a history of gestational diabetes. See the table below for a list of codes that can be used in this type of search.
• Denver Health and Hospital Authority (Denver Health) developed a patient registry based on HER data. That registry included individuals at risk for type 2 diabetes based on program eligibility criteria. The registry was then used to conduct targeted recruitment and referral efforts. Denver Health is a Colorado-based safety net health system; nearly half of its National DPP lifestyle change program participants had Medicaid coverage. The average participant age was 50.

Suggestions from the American Medical Association (AMA) on how health care providers can use their EHR for screening and identification of potential participants for the National DPP lifestyle change program can be found here.

 

Querying a Medical Claim or EHR

There are several billing and procedure codes that could be pulled from a medical claims database or EHR to identify potentially eligible individuals. For example, a query could be set up to pull information required for program eligibility. In instances where a specific lab value is required for inclusion, the actual lab value should be pulled. The program eligibility criteria for the National DPP lifestyle change program are listed below, with potential codes and other query-able elements listed in the columns to the right of each criteria. The presence of an x at the end of the code indicates there are multiple code modifiers or options for each of those codes.

Querying for Eligibility Criteria
Eligibility Criteria	Potential Codes/Elements
Be at least 18 years old	Participant age pulled from EHR
Be overweight (body mass index ≥25; ≥23 if Asian)	BMI specific codes include Z68.3x and Z68.4x Codes associated with obesity include E66.01, E66.09, E66.3, E66.9 Participant race pulled from EHR
Have no previous diagnosis of type 1 or type 2 diabetes	Codes associated with diabetes include E08.xx, E09.xx, E10.xx, E11.xx, E13.xx The presence of any of these diagnosis codes would exclude the participant
Have a blood test result in the prediabetes range within the past year:	Abnormal or impaired glucose codes can be considered, including R73.01, R72.02, R73.09
Hemoglobin A1C: 5.7%–6.4%	CPT code: 83036
Fasting plasma glucose: 100-125 mg/dL	CPT code: 82947
Two-hour plasma glucose (after a 75 gm glucose load): 140-199 mg/dL	CPT code: 82951
Be previously diagnosed with gestational diabetes	ICD-10 codes: O24.410, Z86.32

 
A description of many of these codes, as well as applicable office visit or procedure codes, can be found on the AMA’s list of codes to use when screening for prediabetes and diabetes. While the ICD-10 and CPT codes should be consistent across facilities, how databases are structured and queried is likely to vary. It is important to engage a database expert within your organization early in this process to understand how best to refine your query.
 

Risk Stratification

Once this data is collected, it could then be stratified to determine which individuals are at the highest risk of developing diabetes and could most benefit from this program. Below is an example risk stratification table, informed by information in the cited articles, which could be used to assess potential participants and how broadly or narrow a plan may want to extend access to the program.

Risk Stratification for Type 2 Diabetes Prevention Interventions
Risk Level	Adult Prevalence (%)	10 Years Diabetes Risk (%)	Risk Indicators	Intervention
Very High	~ 15%	>30	A1c >5.7% FPG>110	Structured Lifestyle Intervention in Community Setting
High	20%	20 to 30	FPG>100 NDPP score 9+
Moderate	30%	10 to 20	2+ risk factors	Risk Counseling
Low	35%	0 to 10	0–1 risk factors	Build Healthy Communities

• Sources

• Hertzel C. Gerstein, Point: If It Is Important to Prevent Type 2 Diabetes, It Is Important to Consider All Proven Therapies Within a Comprehensive Approach. Diabetes Care 1 February 2007; 30 (2): 432–434. https://doi.org/10.2337/dc06-2147
• Xuanping Zhang, Edward W. Gregg, David F. Williamson, et al.; A1C Level and Future Risk of Diabetes: A Systematic Review. Diabetes Care 1 July 2010; 33 (7): 1665–1673. https://doi.org/10.2337/dc09-1939

 

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Tracking Eligibility Through a Claims System

A subject’s participation in the program can also be tracked by following the submission of claims as they are received. This provides information on whether or not the participants are both attending and meeting milestones in the program.

For more information on coding for the National DPP lifestyle change program in a claims system, see the Coding and Billing page of the Coverage Toolkit

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Identification by Providers

In other states and implementations, providers have been trained to assist in identifying individuals at risk for type 2 diabetes.

Health Care Provider Videos – Prediabetes and the National DPP

These videos were developed to encourage health care teams to work together and with their patients to identify prediabetes and increase referrals to the National DPP lifestyle change program. These videos were created by NACDD in collaboration with the AMA and through support from the CDC, Division of Diabetes Translation.

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Health Information Exchange Engagement

To reduce type 2 diabetes rates, Maryland Medicaid has worked closely with Chesapeake Regional Information System for our Patients (CRISP), the state designated health information exchange (HIE), to identify individuals eligible for participation in the National DPP lifestyle change program and facilitate referrals through a closed-loop electronic referral process.

CRISP uses various data sources to identify individuals with prediabetes who are likely eligible for the National DPP lifestyle change program. CRISP then generates a “Care Alert” for these individuals that communicates eligibility to their health care provider(s). CRISP also uses monthly “SmartAlerts” to alert MCO case management teams of potentially eligible individuals on their rosters. CRISP’s closed-loop (i.e., bi-directional) referral tool (eReferral) allows health care teams to refer eligible individuals to outside organizations offering the National DPP lifestyle change program, and to receive referral status and enrollment updates on the referred individuals.

To learn more about Maryland’s CRISP prediabetes flag and eReferral tool, please see the CRISP Prediabetes Flag and eReferral Overview document and please watch the June 9, 2022 NACDD General Member Webinar, Making an Impact on Population Health: Utilizing a State-wide Health Information Exchange to Promote the National Diabetes Prevention Program.

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HRSN Screening Tools

HRSN screening tools used at the state and national level can be instrumental in identifying populations and individuals that need additional support to be engaged and retained in the National DPP lifestyle change program. Recent research supports the use of universal screening approaches to identify HRSN. Research continues to be conducted to examine the use of EHR data, community-level data, and machine learning to prioritize screening or predict HRSN among patients. Within the National DPP lifestyle change program, screening can be used as the first step in addressing barriers to participation. This section will discuss several specific screening tools that can be used to address HRSN and further participation in the program.

Organizations can design their own or utilize existing screening tools. Below is a description of three screening tools that can be used to address HRSN: PRAPARE, the Accountable Health Communities (AHC) HRSN Screening Tool, and HealthBegins Upstream Risks Screening Tool. The HRSN Screening Crosswalk compares these three tools side by side.

Content Updated: June 19, 2025