PDF Version
TO: All
Providers
RE: Changes
to Non-Pharmacy Prior Authorization Process
Beginning January 1,
2026, the
Alabama Medicaid Agency (Medicaid) will implement changes to the prior
authorization (PA) process for non-pharmacy PAs to comply with the CMS Interoperability
and Prior Authorization Final Rule. This Final Rule does not apply to pharmacy
PA requests.
To ensure compliance to the
Final Rule, the following changes will be made to the PA process:
- The
rule requires Medicaid to respond to expedited and non-expedited PA requests
within a defined timeline. Medicaid will have 72 hours to provide a response
for expedited requests and seven calendar days to provide a response for
non-expedited requests.
- Expedited
Field – A new field will be available in the provider web portal to indicate
when a request is expedited. By marking a PA as expedited, the provider is
attesting that the recipient’s condition requires an urgent PA determination. Medicaid
will monitor provider use of the expedited field for potential abuse or
overuse.
o Web Portal: Select “Y” for Yes for the Expedited field
o 278 Transaction: Use Loop 2000E – UM06 Level of Service value “Urgent”
- Additional Documentation Timeline – When additional documentation is requested to support a PA decision, providers will have up to 14 calendar days to submit it (reduced from the current 30 business days). If the required documentation is not received within this time frame, the PA will be denied. Providers are encouraged to submit all supporting documentation promptly to avoid delays or denials.
The Current Procedural
Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and
other data are copyright © 2025 American Medical Association and © 2025 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.