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Guides and glossary terms for the coverage journey
Use this hub for plain-English explanations of benefit routes, device coverage concepts, and common terms. Coverage and prior authorization requirements vary by payer and plan.
Guides
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Featured guide
DME vs Pharmacy
Understand the two most common coverage routes for pumps and CGMs.
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Device Catalog
Compare published device records, compatibility references, and coding routes.
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Clinician tools
Billing, documentation, and prior authorization support for clinic workflows.
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Glossary
Common coverage terms
A compact glossary of public terms used throughout the coverage journey.
Billing
3 terms- CPT Code#cpt
- Current Procedural Terminology. Codes used to report medical, surgical, and diagnostic procedures and services to insurers.
- HCPCS Code#hcpcs
- Healthcare Common Procedure Coding System. Codes used by Medicare and other insurers to identify medical equipment and supplies (e.g., E0601 for a CPAP machine).
- NDC Code#ndc
- National Drug Code. A unique 10 or 11-digit number identifying a specific drug product, often used for insulin and sometimes CGMs filled at a pharmacy.
Clinical
8 terms- Automated Insulin Delivery (AID)#aid
- A system that connects a CGM and an insulin pump with an algorithm to automatically adjust insulin delivery (also called "Closed Loop").
- Basal Rate#basal_rate
- A slow, continuous delivery of insulin from an insulin pump that keeps blood sugar levels stable between meals and during sleep.
- Bolus#bolus
- A single, larger dose of insulin delivered by a pump to cover a meal or correct a high blood sugar level.
- CGM Receiver#cgm_receiver
- A dedicated handheld device that displays glucose readings from a CGM sensor.
- CGM Transmitter#transmitter
- A small device that attaches to a CGM sensor and sends glucose data wirelessly to a receiver or smartphone app.
- Continuous Glucose Monitor (CGM)#cgm
- A device that uses a sensor to track glucose levels 24/7, providing real-time data to help manage diabetes.
- Infusion Set#infusion_set
- The tubing and cannula used to deliver insulin from a pump into the body.
- Medical Necessity#medical_necessity
- The criteria an insurance company uses to decide if a treatment or device is required to manage your health condition.
Insurance
21 terms- Appeal#appeal
- A formal request to your insurance company to reconsider a decision to deny coverage for a specific device or service.
- Billing Route#billing_route
- The specific method (Pharmacy vs. DME) your insurance uses to process payment for your equipment.
- Certificate of Medical Necessity (CMN)#cmn
- A formal document signed by your doctor that justifies why you need a specific piece of medical equipment for your insurance to cover it.
- Coinsurance#coinsurance
- The percentage of costs of a covered health care service you pay after you've paid your deductible.
- Copayment (Copay)#copayment
- A fixed amount you pay for a covered health care service after you've paid your deductible.
- Deductible#deductible
- The amount you pay for covered health care services before your insurance plan starts to pay.
- Durable Medical Equipment (DME)#dme
- Medical equipment that is ordered by a doctor for use in the home. This includes insulin pumps and CGM systems.
- Explanation of Benefits (EOB)#eob
- A statement from your health insurance company explaining what medical treatments and/or services were paid for on your behalf.
- Formulary#formulary
- A list of prescription drugs and supplies covered by a specific health insurance plan, often divided into "tiers" that determine your cost.
- In-Network#in_network
- A provider or supplier that has a contract with your insurance plan to provide services at a negotiated rate.
- Medicaid#medicaid
- A joint federal and state program that helps with medical costs for some people with limited income and resources.
- Medical Exception#exception
- A request to your insurance plan to cover a non-preferred or non-covered item because it is medically necessary for your specific situation.
- Medicare Part B#medicare_part_b
- The part of Medicare that covers medically necessary services (like doctor visits) and preventive services, including most insulin pumps and CGMs as DME.
- Medicare Part D#medicare_part_d
- The part of Medicare that covers prescription drugs. Certain wearable pumps (like Omnipod) are often covered here instead of Part B.
- Out-of-Pocket Maximum#out_of_pocket_max
- The most you will have to pay for covered services in a plan year. After you spend this amount, your plan pays 100% of the cost of covered services.
- Pharmacy Benefit#pharmacy_benefit
- Coverage for medications and certain medical supplies that you typically pick up at a retail or mail-order pharmacy.
- Pharmacy Benefit Manager (PBM)#pbm
- A company that manages prescription drug benefits on behalf of health insurers, Medicare Part D plans, and other payers.
- Preferred Product#preferred_product
- A specific brand or device that an insurance company has chosen to cover more favorably than others (often with lower co-pays).
- Quantity Limit#quantity_limit
- A restriction on the amount of a specific item or medication you can receive over a certain period (e.g., 90 days).
- Step Therapy#step_therapy
- A requirement that you must try and "fail" on a less expensive or different brand of treatment before the plan will cover the one your doctor originally ordered.