Prior Authorization and Submission Process

Certain DME, supplies and appliances require prior authorization. The provider must submit the appropriate Alabama Prior Review and Authorization Request Form, any applicable EPSDT/Patient 1st PMP Referral Form, all documentation justifying medical necessity, and the current prescription/order. Prior authorization requests must be received by the Medicaid fiscal agent within 30 calendar days after equipment is dispensed; Medicaid will approve, deny, or place pending and will issue a ten-digit PA number if approved.

• Submit Alabama Prior Review and Authorization Request Form and supporting medical documentation.
• Include EPSDT or Patient 1st PMP Referral Form when applicable.
• Ensure PA request is received within 30 calendar days of dispensing to avoid denial.

Do not bill recipient for PA denials caused by provider error

If a prior authorization is denied due to provider error or the provider's failure to submit necessary medical documentation for the PA request, the provider may not bill the recipient for the item.

Procedures for items not requiring PA

For items that do not require prior authorization, the provider must verify recipient Medicaid eligibility monthly, obtain any necessary managed care or EPSDT referrals, furnish the covered items as prescribed, collect applicable co-payments, retain all documentation for three years plus the current year, and submit the proper claim form to Medicaid's fiscal agent.

• Verify eligibility each month; no reimbursement for months without eligibility.
• Obtain required managed care or EPSDT referrals before dispensing.
• Retain prescription/order, referrals, PA forms and related records for 3 years plus the current year.

Prior authorization required for oxygen therapy

Oxygen therapy must be prior authorized by Medicaid. Requests must be made on the appropriate Alabama Prior Review and Authorization Request Form and accompanied by the required medical and other documentation in accordance with Rule No. 560-X-13-.03.

• Provide evidence of chronic debilitating condition and prior attempts of other treatments; oxygen will not be approved for PRN use only.
• Include all required supporting documentation per the PA submission rules.

Prior authorization required for ACDs

Augmentative Communication Devices (ACDs) are available only through the Alabama Medicaid prior authorization process. Requests must be submitted to Medicaid for review and Medicaid may request additional information or evaluations by appropriate professionals.

• Submit ACD authorization requests via the Medicaid prior authorization process described in Chapter 14.
• Be prepared to provide additional information or professional evaluations if requested by Medicaid.

Prior approval required for wheelchairs (EPSDT rules apply)

All wheelchair requests are subject to Medicaid prior approval per Rule No. 560-X-13-.03 and any additional requirements in Chapter 14; EPSDT-referred wheelchairs have additional submission requirements including MSRP price submissions from manufacturers.

• Follow prior approval procedures in Rule No. 560-X-13-.03 for all wheelchair requests.
• For EPSDT-referred systems, submit MSRPs from three manufacturers (or document non-availability) and expect MSRP-based reimbursement rules.

Prior approval for repairs/replacement; DME Unit review for exceptions

Requests for repair or replacement generally require prior approval and must be submitted electronically to Medicaid's fiscal agent with appropriate documentation; requests outside normal benefit limits or due to extenuating circumstances must be submitted to the DME Unit by mail for review.

• Submit repair/replacement requests electronically with supporting documentation and keep records in recipient file.
• Mail requests that are outside normal benefit limits or due to extenuating circumstances to the Alabama Medicaid DME Unit for review.

Documentation required for loss/theft replacement

For replacements due to disasters, fire, theft, etc., the provider must submit appropriate supporting documentation (e.g., police or fire report) with the prior authorization when applicable, and the date of the report must be within 30 days of the loss or event.

• Include police, fire or other official report with the PA and retain documentation in the recipient's file.
• Ensure report date is within 30 days of the loss/event to qualify for replacement coverage.