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TO:  All Providers

RE: Changes to Body Mass Index Requirement during Public Health    Emergency

Effective August 1, 2021, the Medicaid Agency will reinstate the Body Mass Index (BMI) requirement. Beginning August 1, 2021, Primary Care Physicians (PCPs), nurse practitioners/physician assistants (collaborating with a PCP), PCP groups/ individual PCPs participating with an Alabama Coordinated Health Network (ACHN), Federally Qualified Health Centers, Rural Health Centers, Public Health Departments, Teaching Facilities, and OB/GYNs that bill procedure codes 99201-99205, 99211-99215, and 99241-99245 will be required to include a BMI diagnosis on the claim. The claim will be denied when a BMI diagnosis is not on the claim. A BMI diagnosis will only be required once 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. The claim will be denied when a BMI diagnosis is not on the claim. Some specialists and nurse practitioners/physician assistants collaborating with these specialists are exempt from the BMI requirement. Refer to Chapter 40 of the Alabama Medicaid Provider Billing Manual for a list of provider specialists that are exempt from the BMI requirement.

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 or the Automatic Voice Response System (AVRS).

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. See the screenshot below that details the location of the BMI visits on the recipient’s eligibility benefit panel.

Screenshot Link

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 Alabama Medicaid Provider Billing Manual for BMI override request procedures.

The most current Provider Billing Manual may be accessed with the following link: https://medicaid.alabama.gov/content/7.0_Providers/7.6_Manuals.aspx.

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

Note: During the COVID-19 emergency, it is important to file claims as quickly as possible to ensure payment from Medicaid is made to Medicaid providers close to the date of service. The Centers for Medicare and Medicaid Services has increased the federal matching percentage for the emergency time frame, but states can only receive the increased match on claims that are paid during the emergency.

The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2021 American Medical Association and © 2021 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.