Please see the November 2023 provider update. Previous updates can also be found on the Executive Officer of Health and Human Services (EOHHS) Provider Updates web page.
Also in Rhode Island, Medicaid has noticed an increase in the number of Continuous Glucose Monitors (CGMs) submitted via pharmacy claims. Please note that Medicaid considers CGMs as DME products and requires prior authorization for all CGM-related items. All prior authorization requests must be submitted by the dispensing provider and must include a prescription and recent clinical notes. Requests submitted directly by ordering physicians will be returned.
- Coverage guidelines can be found here: CGM Policy Final 091222.pdf (ri.gov)
- Prior authorization forms and instructions can be found here: Prior Authorization | Executive Office of Health and Human Services
In adherence with recent Medicare HCPCS code updates, Medicaid activated the following CGM codes:
- A4239 – SUPPLY ALLOWANCE FOR NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE
- E2103 – NON-ADJUNCTIVE, NON-IMPLANTED CONTINUOUS GLUCOSE MONITOR OR RECEIVER
Effective October 1, 2023, prior authorization requests submitted under codes K0553 and/or K0554 are being returned and must be resubmitted with the proper codes.
Claim submission for reimbursement must be done using either the 837 professional file format or via the CMS 1500 paper claim. Claims submitted otherwise will be denied.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.