Prior to June 9, 2020, PCPs, NPs/ PAs (collaborating with a PCP), PCP groups/ individual PCPs participating with an ACHN, FQHCs, RHCs, Public Health Departments, Teaching Facilities, and OB/GYNs that bill procedure codes 99201-99205, 99211-99215, and 99241-99245 were required to include a BMI diagnosis on each claim billed. Beginning June 9, 2020, a BMI will only be required on an annual basis for claims to pay. EPSDT procedure codes 99382-99385 and 99392-99395 must also include a BMI diagnosis on the claim annually or the claim will be denied.

How will the change affect specialists?

Some specialists are exempt from the BMI requirement. NPs/PAs collaborating with these specialists are also exempt from reporting the BMI on the claim. Refer to Chapter 40 of the Provider Billing Manual for a list of provider specialties that are excluded from the BMI requirement. Chapter 40 can be accessed by following: www.medicaid.alabama.gov > ‘Providers’ tab > Current manual> Accept agreement > Chapter 40.

How will providers know if a BMI is needed?

Providers may verify BMI reporting on a claim during a calendar year by accessing the recipient’s eligibility benefit panel via Provider Electronic Solutions (PES) Software. The telephone response system will be updated at a later date.

For information on how to access and utilize PES, visit the following link: https://medicaid.alabama.gov/content/7.0_Providers/7.8_PES_Software.aspx. 

Under the Benefit Limits section, a response of “1” (or more) paid BMI visits indicates that the recipient had an annual BMI and a new BMI is not required for the claim to pay. A response of “0” paid BMI visits indicates that the recipient has not had an annual BMI reported and a BMI will be required for the claim to pay. View the attached pdf to see the screenshot below that details the location of the BMI visits on the recipient’s eligibility benefit panel.

What to do if a BMI cannot be determined (e.g. wheelchair-bound recipients)?

In instances where a BMI cannot be determined (e.g., wheelchair-bound recipients), an override request may be submitted after the claim has been filed and denied. See Chapter 40 of the Provider Billing Manual for override request procedures.

Where can a provider go for details regarding the BMI requirement?

Chapter 40 of the Provider Billing Manual contains additional information about the BMI requirement. Chapter 40 can be accessed by following: www.medicaid.alabama.gov > ‘Providers’ tab > Current manual> Accept agreement > Chapter 40.

Who should I contact with questions about the BMI requirement?

For questions related to the BMI requirement, e-mail ACHN@medicaid.alabama.gov.

NOTE: Although the BMI system changes go into effect on 6/9/2020, the changes will not affect nor replace the current waiver of BMI reporting requirement due to COVID-19.