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TO:   All Providers

RE:   EPSDT and PCP Referral Requirements

1.   Effective for dates of service on or after September 1, 2021, the Alabama Medicaid Agency (Medicaid) will resume the EPSDT referral requirement.

How does this impact how claims are to be billed?

Claims will deny and post error status codes on the remittance advices for those claims not indicating the service provided is as the result of an EPSDT referral. Refer to Appendix A–Well Child Checkup (EPSDT) of the Provider Billing Manual for billing instructions for EPSDT services.

How does this impact prior authorizations?

Services requiring prior authorization with an effective date of services on or after September 1, 2021, will be required to have a current EPSDT referral. Prior authorization requests submitted on or after September 1, 2021 will be required to include a current EPSDT referral with the prior authorization.

What types of providers does the EPSDT referral requirement impact?

Any Medicaid provider whose services require an EPSDT referral will be affected. Please refer to the Provider Billing Manual Chapters for the provider type and services performed.

Will the referral form be updated?          

Yes. Form 362, the Alabama Medicaid Referral Form, will be updated and placed on the Medicaid website under the Resources, Forms Library link. 

Link to the Provider Billing Manual:

https://medicaid.alabama.gov/content/Gated/7.6.1G_Provider_Manuals/7.6.1.3G_July2021.aspx

For questions related to the EPSDT referral process, email Jean.Wackerle@medicaid.alabama.gov.

2.   Effective August 1, 2021, Medicaid will no longer require a Primary Care Physician (PCP) referral for services rendered for Medicaid recipients. The removal of the PCP referral requirement is for the following services or provider types:  all specialists, Durable Medical Equipment (DME), outpatient hospital services, nephrology, optometrist/optician services/ophthalmologists, independent nurse, home health, glucose test strips/lancet, children’s orthodontia, anesthesia, and ambulatory surgical centers. The specified provider types or services will no longer be required to indicate a referring provider on claims for reimbursement from Medicaid. Chapter 40 of the Provider Billing Manual will be updated in the October 2021 release. The Alabama Coordinated Health Networks (ACHNs) will no longer issue billing-only referrals after the August 1^st effective date.

For questions related to the removal of the PCP referral requirement, e-mail ACHN@medicaid.alabama.gov.

For questions relating to filing claims relating to the EPSDT referral requirement, please contact the Gainwell Provider Assistance Center at 1-800-688-7989.

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