Changes to Non-Pharmacy Prior Authorization Process

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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:

• 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.

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