Provider Talking Points for Reason Codes on Remittance Advice

Provider Claims FAQ

Provider Talking Points for Carve Out Benefits

What are the CGM coverage requirements under Medicare?

CGMs are covered for members who:

All coverage requests should be submitted through the member’s medical group.  For Medicare coverage policies, please see Local Coverage Determination (LCD): Glucose Monitors (L33822) and Local Coverage Article: Glucose Monitor - Policy Article (A52464).

What are the differences between non-adjunctive vs. adjunctive CGMs?

Non-adjunctive CGMs can be used as a complete replacement for traditional fingerstick blood glucose testing supplies and do not require a separate blood glucose monitor (BGM) to confirm testing results.

Adjunctive CGMs must be used in conjunction with standard finger stick tests using a home BGM to confirm testing results.

Both non-adjunctive and adjunctive CGMs are considered DME.

Why is my patient’s CGM rejecting/not covered at the pharmacy?

CGM supplies are covered under the durable medical equipment (DME) benefit under Medicare. For SCAN members, DME supplies are provided by the medical group’s contracted DME supplier and are not coverable under the pharmacy benefit.

My patient previously received a fill at the pharmacy, why is their CGM refill now rejecting?

Your patient may have received a temporary fill during their first 90 days of enrollment with SCAN at the pharmacy. Known as a transition fill, this allows patients to have access to these CGM supplies while they are new to the plan. This transition fill also allows you time to request authorization (referral) from the medical group to cover and supply CGMs under the DME benefit.

Why are CGMs covered under the DME benefit and not the pharmacy benefit (Part D)?

Medicare covers CGMs under the DME benefit. For SCAN members, this benefit is managed by the medical group and will not be covered at the pharmacy. Please make sure you DO NOT send an authorization request to Express Scripts. They only manage pharmacy authorizations and will not process your request.

What are the next steps to ensure my patient receives their CGMs in a timely manner?

Submit an authorization to your patient’s medical group with the appropriate CGM DME supply codes to ensure the CGM gets covered. 

1. Documentation showing that your patient meets the criteria to use CGM supplies.
2. Prescription for CGM supplies (refer to HCPCS and ICD-10 codes listed above).
3. Documentation showing that your patient’s diabetes diagnosis will be re-evaluated and managed every 6 months.

• Please ensure your patients update their contact information with their local county Medi-Cal office.
• Encourage patients to complete their Medi-Cal paperwork by the due date.
• Medi-Cal does not require a payment in the application or renewal process.
• California Medi-Cal Redetermination Provider Tool Kit

Prior Authorization Requirements

(Available to Los Angeles County members only)

SCAN offers services for members who are experiencing homelessness or who are at risk of losing housing. The following services may be available to you:

• Housing Transition Navigation Services – help with finding and applying for housing
• Housing deposits – help with one-time funding of housing deposits and utility set up fees
• Housing tenancy and sustaining services – help with keeping you housed and maintain safety
• Short-term post-hospitalization housing – provide care in a facility after an inpatient hospitalization
• Recuperative care – short-term care in a medical facility after an inpatient hospitalization