Diabetes Education

Diabetes Education Provider Network (DEPN) Information

Diabetes Education for HMSA Members

HMSA plans include benefits for diabetes education when services are performed by contracted providers. Services from providers who are not registered in the DEPN are not covered.

Diabetes in Pregnancy Program (DiPP) [PDF]

Diabetes education is a benefit under most HMSA plans including:

• Preferred Provider Plan (PPP).
• Health Plan Hawaii and HMO plans.
• Federal Plan 87.
• Hawaii Employer-Union Health Benefits Trust Fund Plan (EUTF).
• Senior plans.
• The HMSA Plan for QUEST Integration Members.
• HMSA Plan for Postal Service Employees.

Federal Employee Program (FEP): The FEP plan includes benefits for diabetes education, which is a stand-alone benefit. FEP should cover diabetes education services through a participating diabetes education provider. Coverage codes for the FEP Federal Employees Health Benefits (FEHB) Program include Standard Option (104, 105, 106), Basic Option (111, 112, 113), and FEP Blue Focus (131, 132, 133). Coverage codes for FEP Postal Service Health Benefits (PSHB) Program include Standard Option (33D, 33E, and 33F), Basic Option (33A, 33B, and 33C), and FEP Blue Focus (35A, 35B, and 35C).

Joining the DEPN:

For providers who wish to join HMSA’s Diabetes Educator Provider Network please follow the steps outlined:

Contact HMSA’s Provider Operations team

• Email: provider_data@hmsa.com
• Fax: 808-948-8210 on Oahu
• Request to be added as a Diabetes Educator and provider the following:
  • Tax ID/Payee name
  • CDCES Certificate

You will be contacted if more information is needed.

For credentialing requirement details, please consult the information outlined below.

HMSA Credentialing Requirements (PPP, HMO, QUEST Integration, Medicare)

DEPN and Credentialing Requirements

Medical Group Diabetes Education Program (PPP, HMO, QUEST Integration, Medicare)

• Programs are covered by HMSA Medical Group Agreement for each line of business that will provide diabetes education services for HMSA members.
• Prior to providing diabetes education services, Medical Group Diabetes Education Programs must submit to HMSA an active American Diabetes Association (ADA) Certificate of Recognition or The American Association of Diabetes Educators (AADE) Certificate of Accreditation.
• Prior to performing diabetes education services, groups must submit to HMSA the registration information for all providers, including MDs, APRNs, RNs, RDs, and PAs.
• Liability insurance for the practitioner is required.
• Registered providers will be added to the DEPN.
• Programs will be re-credentialed every three years.

HMSA Medical Group for Medicare Plans – additional requirement. Please inform HMSA if the practitioner is employed or contracted by the medical group. If the practitioner is contracted, then a copy of the contract signature page between the medical group and the practitioner must be submitted at time of registration.

Medical Group that is not AADE- or ADA-accredited

• Individual practitioners who are covered under the Medical Group Agreement may be registered in the DEPN.
• Practitioner must be credentialed by HMSA.
• Prior to providing diabetes education services, the group must submit to HMSA an active board certification from the National Certification Board for Diabetes Educators (CDE).
• A copy of liability insurance from the carrier is required.
• Programs will be re-credentialed every three years.

Individual Practitioner DEPN (PPP, HMO, QUEST Integration, Medicare)

• Individual practitioners must be credentialed and covered by an HMSA Participating Provider Agreement – Physician or Allied.
• Prior to providing diabetes education services, individual practitioners must submit their CDE to HMSA.
• A copy of liability insurance from the carrier is required.
• Programs will be re-credentialed every three years.

Please review the additional requirements and information on compensation for services provided to HMSA plan members through these programs:

• Diabetes in Pregnancy Program (DiPP) [PDF]
• Medicare Plans – DSMT (Medicare Advantage).
• QUEST Integration – Diabetes Education Program.
• Federal Employee Program (FEP).

Administrative Requirements

Environmental

Providers must furnish services in settings that are conducive to adult learning. The setting should:

• Have adequate lighting and ventilation with minimal ambient noise.
• Be ADA-accessible and reasonably convenient for HMSA members.
• Comfortably accommodate a minimum of three attendees.

Claims Filing

General Directions

Hard-copy claims must be filed using the CMS 1500 Claim Form [PDF]. Comprehensive directions for completing the CMS 1500 claim form can be found in HMSA’s Provider E-Library. Providers who file using electronic media claims (EMC) should file claims in accordance with the data requirements specified by their vendors.

Procedure Codes

You may use one or more of the following HCPCS codes as appropriate.

Note: Providers are asked to provide one hour of training per session. Therefore, when using HCPCS codes G0108 or G0109 to bill for a one-hour training session, the number “2” should be placed in the days or units column (24G) of the CMS 1500 claim form.

Modifiers

If the services are rendered by a certified diabetes educator (CDE), modifier code SW should be appended to the procedure. If services are rendered by other medical professionals, no modifier is needed.

Referring Physician

The name of the referring or ordering physician must appear in Block 17 of the CMS 1500 claim form. If the patient has contacted you as a result of a self-referral or referral through either HMSA’s disease management services or HMSA staff, please contact the physician who is monitoring and treating the patient for diabetes. To ensure continuity of care, the physician should be informed of the patient’s wish to attend classes and of the patient’s progress. If the physician has been contacted, the physician’s name may be entered as the referring or ordering physician. The claim cannot be processed for benefits without the name of the referring physician.

Payment

Payment for services rendered to members of the PPP, Health Plan Hawaii, HMSA’s other HMO plans, the Federal Plan, and EUTF will be made according to the HMSA reimbursement schedule for professional services for diabetes education.

Revision History