Need Help Checking Medicare Eligibility?
MLN Connects logo

Thursday, September 24, 2020


Claims, Pricers & Codes


MLN Matters® Articles


View this edition as PDF (PDF)



CMS to Expand Successful Ambulance Program Integrity Payment Model Nationwide

On September 22, CMS announced that it will expand the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. The model saved Medicare about $650 million over four years while preserving quality of care and access to essential services.

The RSNAT Prior Authorization Model tests whether prior authorization—or advanced approval of a service before the service is furnished and before a claim is submitted for payment—helps save Medicare money while maintaining or improving the quality of care for repetitive, scheduled non-emergency ambulance transportation. With the expansion of this model, CMS is focusing on results and ensuring that the right payments are made at the right time for the right beneficiary for covered, appropriate, and reasonable services. The model began in New Jersey, Pennsylvania, and South Carolina in 2014 and in 2016, North Carolina, Virginia, West Virginia, Maryland, Delaware, and the District of Columbia were added in accordance with section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The model is expanding nationwide under the authority of section 1834(l) (16) of the Social Security Act, as added by section 515(b) of MACRA.

The model’s program integrity, patient safety, and cost-savings elements will continue without interruption in the current states beyond December 1, 2020, when the model was originally scheduled to end in these states. CMS will release more information on the national expansion and implementation dates for additional states as it becomes available. The national model will follow the same design as the current model. CMS is continuing to monitor the Coronavirus Disease 2019 Public Health Emergency and will take that into account when determining the timeframe for expansion into additional states.

For More Information:

See the full text of this excerpted CMS Press Release (issued September 22).


Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Medicare pays Medicare Diabetes Prevention Program (MDPP) suppliers to provide group-based intervention to at-risk eligible Medicare patients:

  • CDC-approved National Diabetes Prevention Program curriculum
  • Up to 2 years of sessions delivered to groups of eligible patients

Find out how to become a Medicare enrolled MDPP supplier:

For More Information:


COVID-19: Maintaining Safety, Critical Care Load-Balancing, & Behavioral Health

The Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) released an Express message with new resources:  

For More Information:


National Cholesterol Education Month & World Heart Day

September is National Cholesterol Education Month, and September 29is World Heart Day. These observances raise awareness about cardiovascular disease, cholesterol, and stroke. Talk to your patients about appropriate Medicare-covered services and screenings. 

For More Information:

Visit the Preventive Services website to learn more about Medicare-covered services.


Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

For a claim to be valid under the Medicare Diabetes Prevention Program (MDPP), you must have both:


If you don’t have a separate Medicare enrollment as an MDPP supplier and you submit a claim for MDPP services, your claim will be rejected.

Medicare enrolled MDPP suppliers: See the Quick Reference Guide to Payment and Billing and Billing and Claims Fact Sheet for information on valid claims:

  • Our Checking Medicare Eligibility (PDF) Fact Sheet tells you how to check your patient’s Medicare eligibility; use the eligibility data to determine if a patient meets the  criteria to receive MDPP services
  • Submit claims when a performance goal is met, and report codes only once per eligible patient (except G9890 and G9891)
  • List each Healthcare Common Procedure Coding System (HCPCS) code with the corresponding session date of service and the coach’s National Provider Identifier
  • Include all MDPP coaches on your Provider Enrollment, Chain and Ownership System application and update within 30 days after a change
  • List all HCPCS codes associated with a performance payment (including non-payable codes) on the same claim
  • Include Demo code 82 in block 19 (Loop 2300 segment REF01 (P4) and segment REF02 (82)) to identify MDPP services
  • Don’t include codes for other, non-MDPP services on the same claim

For More Information:



CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — September 24

Thursday, September 24 from 4 to 5 pm ET

This live Q&A series is brought to you by CMS, CDC, and the Quality Improvement Organization (QIO) Program:

Target Audience: Clinical and administrative nursing home staff members.


MLN Matters® Articles

2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update

CMS issued a new MLN Matters Article MM11968 on 2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update (PDF). Learn about new code files.


National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer

CMS issued a new MLN Matters Article MM11837 on National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer (PDF). Learn about coverage of this diagnostic laboratory test.


Update to the Medicare Claims Processing Manual

CMS issued a new MLN Matters Article MM11958 on Update to the Medicare Claims Processing Manual (PDF). Learn about updates to chapters 12 and 23.


Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries — Revised

CMS revised MLN Matters Article MM11945 on Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries (PDF) to reflect a change to the Medicare Secondary Payer Manual.



Checking Medicare Eligibility

A new Checking Medicare Eligibility Medicare Learning Network Fact Sheet is available. Make sure you bill appropriately for Medicare-covered supplies and services. Find out how to check eligibility through online tools and services:

  • MAC online provider portal or interactive voice response system
  • Health Insurance Portability and Accountability Act Eligibility Transaction System
  • Billing agencies, clearinghouses, or software vendors


Like the newsletter? Have suggestions? Please let us know!

Subscribe to MLN Connects. Previous issues are available in the archive.

This newsletter is current as of the issue date. View the complete disclaimer.

Follow the MLN on Twitter #CMSMLN, and visit us on YouTube.

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health and Human Services (HHS).

Medicare Learning Network logo