Diabetes Prevention Program (DPP)

Applies to Commercial and Medicaid Expansion

Blue Cross Blue Shield of North Dakota (BCBSND) will provide reimbursement to organizations who have obtained certification through the Center for Disease Control (CDC) to administer the National Diabetes Prevention Program (DPP) in North Dakota and meet the below requirements. This program is an evidenced based program designed by the CDC that is focused on helping at-risk participants make positive lifestyle changes such as eating healthier, reducing stress, and increasing physical activity.

Member eligibility:

• Adults (18 and older) who meet either of the following criteria:
  • Diagnosis of Pre-diabetes confirmed with one of the following labs:
    • Lab results of fasting glucose of 100-125 mg/dl
    • 2-hour plasma glucose measured after 75 gm glucose load of 140-199 mg/dl
    • A1c of 5.7- 6.4
  • Adults (18 and older) at risk for Type 2 Diabetes and do not already have diabetes diagnosis
• If the BCBSND or ND Medicaid Expansion member meets the above criteria, verify the member has the DPP benefits by calling the Customer Contact Center number on the back of the member's card or by calling BCBSND: 1-800-368-2312 and/or ND Medicaid Expansion: 1-833-777-5779

Program requirements:

• Year-long program delivered in-person, online or a combination of both
• Include a minimum of 16 weekly sessions during the first 6 months and
• Include a minimum of 6 weekly sessions in the second 6 months
• Program taught by trained lifestyle coaches
• Program includes group support (recommend 10-25 participants)
• Organizations offering national DPP lifestyle program can use a curriculum developed by the CDC or may develop their own curriculum and submit for approval by the CDC

Provider requirements:

• Provider must be a CDC recognized site in either fully, preliminary or pending recognition status
• Provider organization NPI number is required
• Provider must be credentialed with BCBSND as a Diabetes Prevention Provider in ND by completing credentialing application specific to DPP
  • If provider is in preliminary or pending status with the CDC, they must submit their CDC letter with the credentialing application 
  • Complete the Healthcare Organization Credentialing Application through the Availity Essentials
    • If you are not registered with Availity Essentials click here to register

Billing and Coding Requirements

Billing criteria:

• Claims should be submitted electronically or on the CMS-1500 paper claim form
  • Note- Paper claim submission is not allowed for ND Medicaid Expansion services
• The taxonomy code of 174H00000X is required
• Do not include the rendering/performing provider on the claim submission
• Claims should be submitted when performance goal is met
• Provider organization must follow the below billing and coding requirements

*Modifiers VM and 95 must be reported to indicate service was provided via telehealth.

Core Session Requirements

Core sessions:

• Member must attend one core session to initiate services
• Provider organization is paid based on attendance regardless of members weight loss

Core maintenance sessions:

• Payments are made in two 3-month intervals
• Payment is based on the member meeting attendance goals
• Payment is increased if the member also meets the 5% wt. loss goal

Ongoing maintenance sessions:

• Payments are made in four 3-month intervals
• Payment is made if the member attends 2 ongoing maintenance sessions and meets the 5% weight loss goal during the interval

Additional Resources

More information about becoming a DPP recognized site can be found at https://www.cdc.gov/diabetes/prevention/program-providers.htm.

Additional information on the North Dakota DPP program can be found at https://www.ndc3.org.