Authorization and referral

Identifying CPTs require prior authorization

Identifying Services Requiring Prior Authorization

The Alabama Medicaid Agency is responsible for identifying services that require prior approval. Prior authorization is generally limited to specified nonemergency services. The following criteria may further limit or further define the conditions under which a particular service is authorized:

• Benefit limits (number of units or services billable for a recipient during a given amount of time)

• Age (whether the procedure, product, or service is generally provided to a recipient based on age)

• Sex (whether the procedure, product, or service is generally provided to a recipient based on gender)

To determine whether a procedure or service requires prior authorization, access the Automated Voice Response System (AVRS). Refer to Section L.6, Accessing Pricing Information, of the AVRS Quick Reference Guide

For all Magnetic Resonance Imaging (MRI) scans, Magnetic Resonance Angiogram (MRA) scans, Computed Tomography (CT) scans, Computed Tomography Angiogram (CTA) scans, and Positron Emission Tomography (PET) scans performed on or after March 2, 2009, providers will be required

to request prior authorization from MedSolutions. Scans performed as an inpatient hospital service, as an emergency room service, or for Medicaid recipients who are also covered by Medicare are exempt from the PA requirement. Refer to Chapter 22, Independent Radiology, for the diagnostic imaging procedure codes that require prior authorization.

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When a recipient has third party insurance and Medicaid, prior authorization must be obtained from Medicaid if an item ordinarily requires prior authorization. This policy does not apply to Medicare/Medicaid recipients.