MedicaidCoverageHigh impact
REVISED: Continuous Glucose Monitor (CGM) Systems and Supplies – Effective 6/1/2026
Arkansas Medicaid·AR · Endocrinology, Pediatrics, Internal Medicine +2 more·Laboratory & Genetics
Effective date
Sep 1, 2026
We identified it
Jun 3, 2026
Summary
Arkansas Department of Human Services expanded Medicaid coverage for Continuous Glucose Monitor (CGM) systems and supplies effective September 1, 2026, under ACT 623. DME providers (PT 16) can now submit CGM claims via two pathways: prior authorization for HCPCS A and E codes (reimbursed at Medicare fee schedule) or pharmacy claims through Prime portal (reimbursed at WAC plus professional dispensing fee). All CGM codes require prior authorization regardless of billing pathway.
Action Required
By September 1, 2026: Billing team must implement two concurrent workflows for CGM billing. (1) For HCPCS A and E codes: Update billing system to require prior authorization for codes A4238, A4239, E2102, and E2103 with all modifiers (KF, NU, KF NU). Submit PA requests to Prime Therapeutics via fax (800-424-7976) using the DME PA Request form. (2) For pharmacy pathway: Update billing system to submit CGM claims through Prime portal (established 8/1/2024) with reimbursement at WAC plus professional dispensing fee. Configure system to recognize diagnosis groups 645 and 756 for adjunctive CGM codes; non-adjunctive codes require PA but have no specific diagnosis group restrictions. Ensure all claims require prior authorization approval before submission regardless of billing pathway. Update provider documentation templates to clarify pregnancy-related modifiers (NU) for female beneficiaries. Train billing and prior auth staff on both submission methods and contact Prime Therapeutics at 800-424-7895 (Pharmacy Support Option 1) or 800-424-7976 (fax) for questions. Failure to obtain required prior authorization will result in claim denials.