Referral Process

A clear process for encouraging, receiving, and processing referrals is key to creating a sustainable DSMES service. This process includes managing relationships with external providers, determining participant eligibility for diabetes self-management training (DSMT)* coverage, knowing when to refer, completing documentation, and ensuring proper follow-up.

Referring and treating a person with diabetes requires a team-based approach. The most successful DSMES services are those that clearly define each team member’s roles and responsibilities. For example, one team member may be responsible for processing all incoming DSMES service referrals, while another is responsible for follow-up with the referring provider.

Referring providers, diabetes care and education specialists (DCESs), and DSMES service staff can use tracking systems and reminders to manage attendance and follow-up. It is also important for DSMES services and DCESs to identify and address other barriers to participation.

*Note: The Centers for Medicare & Medicaid Services (CMS) uses the term “training” (DSMT) instead of “education and support” (DSMES) when defining the reimbursable benefit (DSMT). This term relates specifically to Medicare billing.

Participant Eligibility

To qualify for DSMT coverage, a participant must have:

• Documentation diagnosis of type 1, type 2, or gestational diabetes.
  • Diagnosis can occur before Medicare Part B enrollment.
• Diagnosis must be made using the following criteria:¹

  Participant Eligibility

  TEST	VALUE
  Fasting Blood Glucose	≥126 mg/dL on two separate occasions
  2-Hour Post-Glucose Challenge	≥200 mg/dL on two separate occasions
  Random Glucose Test	>200 mg/dL with symptoms of uncontrolled diabetes

• A written referral from the treating physician or qualified nonphysician practitioner (such as a physician assistant, nurse practitioner, or advanced practice nurse).¹⁵

Diabetes Education and Referral Algorithm

In 2020, a joint consensus statement was issued on the importance of DSMES in type 2 diabetes.¹ The consensus statement includes evidence-based information on four critical times to refer people with type 2 diabetes to DSMES services:

1. At diagnosis.
2. Annually or when not meeting treatment targets.
3. When complicating factors develop.
4. When a transition in life or care happens.

See Figure 1 for the four critical times to refer.

Referral Requirements and Documentation

DSMES services will be covered by Medicare for enrolled recipients if the treating physician or qualified practitioner documents the need for DSMES in a referral or order. There are many documentation requirements for referrals. Depending on the place of service (e.g., Federally Qualified Health Center, rural health center, hospital), extra or different documentation may be required.

The referring provider must keep the care plan and supporting documentation in the participant’s medical record. In addition, the DSMES service must retain the original referral and any other special conditions noted by the referring practitioner. The referring provider should sign any changes to the order, and the DSMES service should retain a record of those changes.

For more information on referral requirements and documentation, see the resources below:

DSMES/T and Medical Nutrition Therapy (MNT) Services
This document provides background on why referral forms look the way they do.

Diabetes Self-Management Training (DSMT) Accreditation Program

Sample referral forms:

DSMES/T Sample Order Form

Sample Short Referral Form