Device Guide: How to Order & Verify Eligibility

Handling All Device Eligibility & Ordering Inquiries

When a member asks, "Am I eligible for a scale?" or "How do I order this?", do not guess. Check their eligibility using the Device Ordering Eligibility Looker.

The Looker Investigation Workflow

To determine eligibility, agents must verify the data in the Device Ordering Eligibility Looker report:

Step 1-Filter by Organization: In the "Device Rules by Paying Organization" table, select the member's PayOrg to see the specific Program, Condition, and HTN logic required.

Step 2-Search Member: Paste the member's UUID into the search box to view "Device Ordering Eligibility by Member".

Step 3- Look at the column for the specific device (Scale, Cuff, Meter).

• TRUE: The member is eligible to receive the order form.

• FALSE: The member is not eligible. See "Troubleshooting" section below for deep-dive investigation.

The Ordering Process

• Members must complete an in-app survey (sent up to 4 times) to confirm they don't already own a qualifying device.

• The order form is only sent after the survey is complete.

• It takes up to 72 hours after the initial consult w/ the RD for the forms to generate.

• Check Form Status: Use the "Device Order Form Details" table in the Looker to see if the form is Initialized (sent to To-Do list) or Complete (filled out).

• Manual Order Assist: If the member cannot complete the survey, or has incorrectly filled it out support can manually assist with ordering the device. T1 can complete all steps to verify eligibility with the member and T2 can add the request to the device order sheet and update the ticket status once the order has been placed. 

Continuous Glucose Monitor (CGM) Ordering

Check their eligibility using the Device Ordering Eligibility Looker.

Ordering a CGM (Excluding Walgreens + CapRx) requires a strict review of multiple clinical criteria.

Process

1. Check All Criteria: Review the table below to find the specific block.

2. Submit JIRA: If any item is blocked, submit a [System] Service Request to JIRA via the Zendesk app-panel.

3. JIRA Details: The JIRA ticket must include a list of all checked criteria and a clear explanation of the issue.

CGM Eligibility Check (Must Pass All)

Checking Max Med Score (MMS)

Tier 2 only has access to the MMS looker. If T1, escalate to tier 2 to check. MMS must be confirmed for members of clients with MMS criteria for both blood glucose (BGM) (most orgs require 3 or higher but check VP card for confirmation) and continuous glucose meters (CGM) (Most orgs require 5 or higher check VP card for confirmation).

• Claims Data (Preferred): Run the member’s UUID in the Max Med Score User Lookup Looker report.

• Manual Check (If no Looker result): Ask the member for their diabetes medications. Look up the medication class using the [max med score_details] Google sheet to determine the MMS.

 Medication Complexity Score is calculated based on level of diabetes medications a member is on

• 1 no diabetes medication
• 2 - metformin
• 3 - other diabetes medications (SGLT-2, GLP-1, DPP-4, acarbose, TZDs)
• 4 - sulfonylureas
• 5 - long acting insulin
• 6 - multiple short acting insulin

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Withings Blood Pressure Monitor (BPM) Eligibility Check

Check their eligibility using the Device Ordering Eligibility Looker.

• Check Payer Requirements: Verify if the Paying Organization has a specific eligibility requirement related to Blood Pressure (BP) readings (Use "HTN Logic" column in Looker).

• Request Latest BP: If a requirement exists, ask the member to either:

  • Log their latest BP reading in the app.

  • Provide their latest BP reading directly.

• Confirm Eligibility: Use the reading provided to determine device eligibility.

• Confirm Size: Confirm their arm circumference to determine what size of BMP is needed (follow the device order macro template).

Exceptions for Device Orders (Tier 2 Approval Required)

Check their eligibility using the Device Ordering Eligibility Looker.

Device Specifications and Troubleshooting

Check their eligibility using the Device Ordering Eligibility Looker.

Troubleshooting Eligibility via Looker

If a member's eligibility is "FALSE" in the Looker, check the specific Device Type Tab (e.g., Scale Eligibility) to find the failure point:

• Program/Conditions: Is the member in the correct program with the included conditions (e.g., Diabetes, HTN).

• Survey/Consult: Has the member answered the device survey and completed their RD consult.

• Prior Orders: Ensure the "Does Not Have Device Prior" field is TRUE.