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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

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

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?

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:


For questions
related to the EPSDT referral process, email



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 1st effective date.


For questions
related to the removal of the PCP referral requirement, e-mail


For questions
relating to filing claims relating to the EPSDT referral requirement, please
contact the Gainwell Provider Assistance Center at 1-888-688-7989.

The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 20
21 American Medical Association and © 2021 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.


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