Alabama AL
AL Medicaid: NO comprehensive risk-based MCO program — AL is one of a handful of states that remain largely FFS. Care delivery: Patient 1st PCMH (Primary Care Case Management since 1997) is the foundation; Alabama Coordinated Health Network (ACHN, 7 regional networks since 2019) provides care coordination + select services on top of FFS. ACHNs are NOT full-risk MCOs — they receive PMPM care-coordi
AL Medicaid: NO comprehensive risk-based MCO program — AL is one of a handful of states that remain largely FFS. Care delivery: Patient 1st PCMH (Primary Care Case Management since 1997) is the foundation; Alabama Coordinated Health Network (ACHN, 7 regional networks since 2019) provides care coordination + select services on top of FFS. ACHNs are NOT full-risk MCOs — they receive PMPM care-coordination fees + shared savings. PA goes to AMA via the Alabama Medicaid Provider Web Portal. Pharmacy is state-administered. NOT a WISeR pilot state.
Who administers prior authorization in Alabama
Structural facts on file
Alabama Medicaid PA is FORM-DRIVEN FFS, not per-service criteria PDFs (MA) nor a 5-step process model (WA). Authority = Alabama Medicaid Agency (AMA); fiscal agent Gainwell/DXC operates the Provider Web Portal; pharmacy state-administered (Magellan fiscal agent). NO comprehensive risk-based MCO. ACHN provides care coordination only. SHAPE: Operational entry is a master list of numbered PA FORMS (Form 342 Prior Review & Authorization Request is the universal PA form; plus service-specific forms: 343 Dental, 360 Oxygen, 384/386 Wheelchair, 480 ACD, 351 Synagis, 369/389 Pharmacy/Opioid, 409/412/413 Pharmacy overrides, PHY-96-11 Cochlear, 470 Smoking Cessation, ABA Therapy forms, Rehabilitative Services). PA goes to AMA via Gainwell Provider Web Portal. WHERE CRITERIA LIVE: The authoritative cross-cutting clinical-criteria/PA-process source is the PROVIDER BILLING MANUAL, Chapter 4 'Obtaining Prior Authorization', plus PA sections inside per-provider-type billing chapters (8-111). The Provider Billing Manual is GATED behind an AMA CPT/CDT license click-through ('I Accept' button #btnAgreement) — NOT a login. Once accepted, chapter PDFs are public (Apr26_NN.pdf). Discrete clinical CRITERIA are also published openly for select services: Synagis criteria, Form 369/389 pharmacy criteria/instructions, Form 409/412 & 413 pharmacy override external criteria. Radiology (CT/CTA/PET/MRA/MRI) and Cardiology PA are DELEGATED to eviCore/CareCore (evicore.com / carecorenational.com) via the Web Portal. REPIN: state_meta primary_source_urls.pa_index (3.7.1_Forms_PA.aspx) is DEAD (404). Site reorganized. New canonical PA hub = /content/7.0_Providers/7.7_Prior_Authorization.aspx; PA forms = /content/9.0_Resources/9.4_Forms_Library/9.4.14_Prior_Auth_Forms.aspx. HARVESTED 6 PDFs to Corsair: Ch.4 PA manual (gated, AMA-license-accepted), Synagis criteria, Form 369/389 criteria, Form 409/412 override criteria, MME override criteria, Non-Covered Services list.
Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.
Last award: 2024 (procurement RFP 2023-ACHN-01 issued 12/29/2023). Next due: 2029 (next RFP cycle expected). Contracts extended through: None.
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## 1. How AL requires PA Alabama Medicaid requires prior authorization (PA) for a variety of medical services and drugs to ensure the appropriateness and necessity of these treatments. The specific criteria for PA vary depending on the service or drug in question. For instance, Synagis (nirsevimab) requires PA based on specific patient conditions such as gestational age, chronic lung disease, and heart disease. Alzheimer’s Agents, Antidepressant Agents, and Opioid Dependence Agents also necessitate PA, with documentation of medical necessity and prior treatment trials for non-preferred drugs. Additionally, Morphine Milligram Equivalents (MME) daily cumulative overrides require prescribers to document a review of the Prescription Drug Monitoring Program (PDMP), patient education on naloxone, counseling on pregnancy risks, and justification for treatment. For imaging services like MRI, MRA, CT, CTA, PET scans, Nuclear Cardiology, Diagnostic Heart Catheterization, Stress Test (ECHO), Transesophageal ECHO, and Transthoracic ECHO, PA is required from eviCore, which can be submitted via phone, fax, or their website. ## 2. How AL publishes and reports PA Alabama Medicaid publishes its PA criteria in various documents such as the Provider Billing Manual Chapter 4 and open per-service criteria PDFs. The Synagis PA criteria are detailed in a specific document effective October 1, 2024, while Alzheimer’s Agents, Antidepressant Agents, and Opioid Dependence Agents have their own set of instructions effective April 1, 2025. The Pharmacy Override for Therapeutic Duplication and Ingredient Duplication is governed by another document effective January 1, 2024. The MME override criteria are outlined in a separate document effective August 1, 2019. These documents are accessible through the Alabama Medicaid Provider Web Portal, which is operated by Gainwell/DXC as the fiscal agent. ## 3. AL's CMS-0057-F and PA-reform compliance posture Alabama Medicaid’s compliance with CMS-0057-F and PA reform efforts is not explicitly detailed in the provided findings or documents. The state has several 1115 waivers, including SMI/IMD Demonstration (Baldwin & Mobile counties), SUD Demonstration (statewide), Community Waiver Program (IDD; 1915(c) + 1115), and Plan First (family planning). WISeR (CMS "Wasteful and Inappropriate Service Reduction," a Medicare prior-authorization model) does not apply to Alabama — it runs in only six states (AZ, NJ, OH, OK, TX, WA). There is no direct reference to CMS-0057-F compliance in the source documents. The state’s PA process is form-driven for fee-for-service (FFS) payments, with criteria detailed in the Provider Billing Manual Chapter 4 and open per-service criteria PDFs. ## 4. How AL runs its own program Alabama Medicaid operates a state-centralized PA model: the state-run Provider Web Portal routes PA requests rather than delegating to per-plan PA grids. The Alabama Medicaid Agency (AMA) has authority over the PA process, and Gainwell/DXC operates the Provider Web Portal. Pharmacy services are state-administered with Magellan as the fiscal agent. The state’s 1115 waivers cover various demonstrations including SMI/IMD, SUD, IDD, and family planning. (Note: claims in the raw synthesis about a comprehensive risk-based MCO program with a five-year procurement cycle, a 2024 award, and a 2029 RFP are not supported by the source documents and appear fabricated — Alabama has not operated a comprehensive risk-based MCO program; treat any MCO references here as unverified.) ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **State-Centralized Portal**: Alabama uses a state-run portal to manage PA requests, distinct from per-plan PA-grid systems. - **Form-Driven FFS**: The PA process for fee-for-service payments is form-driven with detailed criteria in the Provider Billing Manual and open PDFs. - **1115 Waivers**: Alabama has multiple 1115 waivers covering various health demonstrations. ### Missing/Uncertain: - **Gold Card Law**: The status of the Gold Card law is unspecified, which could impact certain PA processes for high-cost drugs or services. - **WISeR**: Not applicable to Alabama. WISeR is a Medicare prior-authorization model in six states only (AZ, NJ, OH, OK, TX, WA); the placeholder finding is not a signal. - **Foster Care Program Details**: The specifics of Alabama’s foster-care MCO program are unspecified, leaving gaps in understanding how PA processes might differ for this population. - **Comprehensive Risk-Based MCO**: There is no mention of a comprehensive risk-based MCO model, which could be relevant to the state's overall Medicaid strategy and PA requirements.