Background
On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F). This Final Rule requires Alabama Medicaid to process prior authorization (PA) requests under the medical benefit within seven calendar days, and expedited PA requests within 72 hours, effective January 1, 2026. Metrics about processed PAs must also be made available on a public website annually, effective March 31, 2026. These timelines and public reporting requirements apply to PAs for medical items and services only, excluding Pharmacy PAs.
Effective January 1, 2026, the Alabama Medicaid Agency (Medicaid) and its contractors will adjudicate standard PA requests within seven calendar days of receipt, and expedited requests within 72 hours when the beneficiary’s clinical condition requires urgent attention and processing delays could negatively affect health outcomes, provided all necessary documentation is included. This includes all relevant beneficiary information about the beneficiary, clinical attachments, and any additional notes required to demonstrate compliance with the PA submission standards. For detailed submission requirements, please refer to the specific Alabama Medicaid Provider Billing Manual chapters.
If a PA request is submitted with missing or incomplete documentation, Medicaid may request additional information to complete the review. Providers will have up to 14 calendar days to submit the requested documentation. During this period, the PA review timeline may be extended until additional information is received. If the requested documentation is not received within the 14-day time frame, the PA request will be denied.
Effective March 31, 2026, Medicaid will report aggregated PA metrics at www.medicaid.alabama.gov. Specifically, this includes a list of medical items and services (excluding pharmacy) that require PA, as well as data on PA requests (at the procedure code level) for those items and services (e.g., approvals, denials, etc.) over the previous calendar year.
Questions?
If you have any questions regarding the PA updates, please feel free to reach out to us through the following contact methods:
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For Providers: Please consult the Provider Billing Manual or call the Provider Assistance Center at 1-800-688-7989 for current requirements. Hours: Monday-Friday, 8:00 a.m. to 5:00 p.m. (Central Time)
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For Beneficiaries: If you have questions about whether a medical service or item requires PA, please call the Alabama Medicaid Beneficiary Call Center at 800-362-1504 (toll-free) for assistance. Beneficiary Services representatives can help you understand PA requirements and coverage for your specific healthcare needs. Hours: Monday through Friday, 8:00 a.m. until 4:30 p.m. (Central Time)
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For hearing-impaired Beneficiaries: TTY (800) 253-0799
If you have questions on the data from metrics reporting contact Alabama Medicaid at
Phone: 334-242-5000
Mail: PO Box 5624
Montgomery, AL
36103-5624
Additional Resources