Rule 5160-8-53. Diabetes prevention and self-management training

119.03 (A) Definitions. For the purposes of this rule, the following definitions apply: (1) "Diabetes self-management training" (DSMT) is the education and instruction of an individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs. (2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control and prevention (CDC) designed to assist at-risk individuals from developing type 2 diabetes. (B) DSMT. (1) Providers. (a) Rendering providers. The following providers may render or supervise a DSMT service: (i) A physician; (ii) A physician assistant; (iii) An advanced practice registered nurse; (iv) A registered nurse; (v) A registered dietitian nutritionist; or (vi) A pharmacist. (b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for a DSMT service on behalf of a rendering provider: (i) A physician; (ii) A physician assistant; (iii) An advanced practice registered nurse; (iv) A licensed or registered dietitian; (v) A pharmacist; (vi) A professional medical group; (vii) A federally qualified health center; (viii) A rural health clinic; (ix) An ambulatory health care clinic; or (x) A hospital. (2) Coverage. (a) Payment for diabetes self-management training can be made when the following criteria are met: (i) The individual has a current diagnosis of diabetes. (ii) The individual has not previously received diabetes self-management training. (iii) Training is provided in a setting other than an inpatient hospital or an emergency department. (b) Payment may be made, with prior authorization in accordance with rule 5160-1-31 of the Administrative Code, for follow-up sessions not to exceed a total of two hours of individual training or group training in any combination. (C) NDPP. (1) Providers. (a) Rendering providers. The following providers may render or supervise an NDPP service: (i) A physician; (ii) A physician assistant; (iii) An advanced practice registered nurse; (b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for an NDPP service on behalf of a rendering provider: (i) A physician; (ii) A physician assistant; (iii) An advanced practice registered nurse; (iv) A professional medical group; (v) A federally qualified health center; (vi) A rural health clinic; or (vii) An ambulatory health care clinic; (2) Coverage. (a) Payment for an NDPP service can be made when all of the following criteria are met: (i) The individual is eighteen years or older; (ii) The individual is overweight; (iii) The individual is not currently pregnant; and (iv) The individual does not have a diagnosis of type 1 or type 2 diabetes. (v) At least one of the following criteria is met: (a) The individual has been diagnosed with prediabetes; (b) The individual has a history of gestational diabetes; or (c) The individual has had a high-risk result on a prediabetes test. (D) Claim payment. (1) No payment will be made for a DSMT or NDPP service provided on the same date of service as medical nutrition therapy. (2) Payment for a covered service performed in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code. (3) Payment for a covered service rendered by a federally qualified health center (FQHC) or rural health clinic (RHC) is made in accordance with Chapter 5160-28 of the Administrative Code. (4) Payment for a covered service rendered in any other setting is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code. Last updated January 3, 2022 at 9:49 AM Supplemental Information Authorized By: 5164.02 Amplifies: 5164.02 1/1/2027 Disclaimer Contact About