§ 424.59 - Requirements for Medicare diabetes prevention program suppliers.

§ 424.59 Requirements for Medicare diabetes prevention program suppliers.

Cross Reference

Link to an amendment published at 82 FR 53364, Nov. 15, 2017.

(a) Conditions for enrollment. An entity may enroll as an MDPP supplier if it satisfies all of the following criteria and meets all other applicable Medicare enrollment requirements:

(1) At the time of enrollment has full CDC DPRP recognition.

(2) Has obtained and maintains an active and valid TIN and NPI at the organizational level.

(3) Has passed application screening at a high categorical risk level per § 424.518(c).

(4) All coaches who will be furnishing MDPP services on the entity's behalf have obtained and maintain active and valid NPIs.

(5) Submits a roster of all coaches who will be furnishing MDPP services on the entity's behalf that includes the coaches' first and last names, SSN, and NPI.

(b) Documentation retention and provision requirements. An MDPP supplier must maintain all documentation in accordance with § 424.516(f) and all other federal and state laws. The MDPP supplier must submit any documentation requested by the government or a contractor to substantiate the attestations or claims submitted for payment under the Medicare program.

(1) The records must contain documentation of the services furnished including evidence of the beneficiary's eligibility, specific session topics attended, the NPI of the coach who furnished the session attended, the date and place of service of sessions attended, and weight.

(2) MDPP suppliers are required to maintain and handle any beneficiary PII and PHI in compliance with HIPAA, other applicable privacy laws and CMS standards.

(3) The MDPP supplier must maintain a crosswalk between the beneficiary identifiers submitted to CMS for billing and the beneficiary identifiers submitted to CDC for beneficiary level-clinical data.

(4) The records must include an attestation from the supplier that the MDPP eligible beneficiary for which it is submitting a claim:

(i) Has attended one, four or nine core sessions, or

(ii) Has achieved the required minimum weight loss percentage specified in § 410.79 of this chapter, or

(iii) Has achieved maintenance of weight loss and attended core maintenance sessions, or

(iv) Has achieved maintenance of weight loss and attended ongoing maintenance sessions.

(c) Conditions for payment of claims for MDPP services furnished. An MDPP supplier must meet all of the following requirements in order to receive payment for claims made for MDPP services furnished:

(1) Establishes and maintains all enrollment and program requirements under Title 42.

(2) Submits attestation as specified in paragraph (b) of this section.

(d) Revocation of MDPP supplier enrollment. An MDPP supplier is subject to revocation of its MDPP supplier enrollment if:

(1) It loses its CDC DPRP recognition or withdraws from seeking CDC DPRP recognition.

(2) One of the revocation reasons specified in § 424.535 applies.

(e) Procedures for revoking or denying MDPP supplier enrollment.

(1) MDPP suppliers are subject to the enrollment regulations set forth in subpart P of this part.

(2) An MDPP supplier that has had its MDPP supplier enrollment revoked may:

(i) Become eligible to bill for MDPP services again if it meets the requirements of paragraph (a)(1) of this section, and enrolls again in Medicare as an MDPP supplier subject to paragraph (a) of this section.

(ii) Appeal in accordance with the procedures specified in 42 CFR part 405, subpart H, 42 CFR part 424, and 42 CFR part 498. References to suppliers in these sections apply to MDPP suppliers.

[81 FR 80558, Nov. 15, 2016; 81 FR 81698, Nov. 18, 2016]