The Alabama 390 form is a request form used for obtaining prior authorization for pharmacy services under the Alabama Medicaid program. This form is essential for healthcare providers to ensure that prescribed medications meet the necessary guidelines for approval. By completing the Alabama 390, prescribers can facilitate access to required treatments for their patients, ensuring they receive the care they need.
The Alabama 390 form serves as a crucial tool for healthcare providers seeking prior authorization for pharmacy services under the Alabama Medicaid program. This form is specifically designed to facilitate requests for medications and compounding services that may not be readily available or covered under standard guidelines. It includes sections for patient information, prescriber details, and dispensing pharmacy data, ensuring that all relevant parties are clearly identified. Additionally, the form requires detailed clinical information, including drug requests, diagnosis codes, and medical justification, which must be provided to support the need for the requested treatment. By certifying the necessity of the treatment, prescribers affirm their commitment to overseeing the patient's care. The form also accommodates requests for compounding services, allowing for the inclusion of specific ingredients and time requirements. Ultimately, the Alabama 390 form streamlines the communication process between healthcare providers and the Alabama Medicaid Agency, ensuring that patients receive the necessary medications in a timely manner while adhering to regulatory guidelines.
Alabama Medicaid Pharmacy
Miscellaneous PA Request Form
FAX: (800) 748-0116
Fax or Mail to
P.O. Box 3210
Phone: (800) 748-0130
Health Information Designs
Auburn, AL 36832-3210
PATIENT INFORMATION
Patient name
Patient Medicaid #
Patient DOB
Patient phone # with area code
Nursing home resident ❒ Yes
PRESCRIBER INFORMATION
Prescriber name
NPI #
License #
Phone # with area code
Fax # with area code
Address (Optional)
Street or PO Box /City/State/Zip
I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency. I will be supervising the patient’s treatment. Supporting documentation is available in the patient record.
Prescribing practitioner signature
Date
DISPENSING PHARMACY INFORMATION
Dispensing pharmacy Phone # with area code NDC #
Fax # with area code Drug Requested
DRUG/CLINICAL INFORMATION
Required for all requests
❒
Drug request – Complete this section
Quantity per month
Compounding Professional Fee – Complete items marked ◆ and next section
PA Refills:
0 1 2 3 4 5 Other
◆ Diagnosis
ICD-9
Code*
◆ ❒ Initial Request
◆
❒ Renewal
◆Medical justification
◆ ❒ Additional medical justification attached.
❒ EPSDT Referral form attached
*See Instruction Sheet, Section 4
COMPOUNDING SPECIFIC INFORMATION
Compounding Ingredients (Ing.)
Ing. Name
If more ingredients are required, attach additional sheets.
Compounding Time
Units Requested (in minutes)
FOR HID USE ONLY
❒ Approve request
❒ Deny request
❒ Modify request
❒ Medicaid eligibility verified
Comments
Reviewer’s Signature
Response Date/Hour
FORM 390
Alabama Medicaid Agency
Revised 2/23/08
www.medicaid.alabama.gov
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The Alabama 390 form, which is used for requesting prior authorization for pharmacy services, shares similarities with the CMS-1500 form. The CMS-1500 form is a standard claim form used by healthcare providers to bill Medicare and other insurance programs. Both forms require detailed patient and provider information, including identification numbers and contact details. They also necessitate a certification that the treatment is necessary and aligns with established guidelines. This ensures that the services provided are justified and that there is a clear record of the transaction for reimbursement purposes.
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Another document akin to the Alabama 390 form is the Prior Authorization Request Form used by private insurance companies. Much like the Alabama 390, this form is designed to obtain approval before certain medications or treatments are dispensed. Both documents require the prescriber to provide information about the patient, the requested drug, and the medical justification for the request. This process aims to control costs and ensure that patients receive appropriate care based on their specific health needs.
The Drug Utilization Review (DUR) form also bears resemblance to the Alabama 390 form. DUR forms are utilized to evaluate the appropriateness of prescribed medications, ensuring they align with clinical guidelines and patient safety standards. Similar to the Alabama 390, the DUR process involves collecting patient information, medication details, and justifications for the prescribed treatment. Both forms emphasize the importance of monitoring medication use to prevent adverse effects and enhance the overall quality of care.
Lastly, the Medication Prior Authorization Request Form from the Veterans Affairs (VA) system is comparable to the Alabama 390 form. This VA form is used to request approval for specific medications for veterans, ensuring that they receive necessary treatments. Like the Alabama 390, it requires detailed patient and prescriber information, along with a justification for the medication request. Both forms aim to streamline the approval process while safeguarding the health and well-being of patients by adhering to established medical guidelines.
When filling out the Alabama 390 form, there are several important points to keep in mind. This form is essential for requesting prior authorization for certain medications through Alabama Medicaid. Here are some key takeaways:
By following these guidelines, you can help ensure that the Alabama 390 form is filled out correctly and submitted efficiently, which can lead to quicker approvals for necessary medications.
The Alabama 390 form is primarily used to request prior authorization for certain medications through the Alabama Medicaid program. This form ensures that the prescribed treatment is both necessary and adheres to the guidelines set by the Alabama Medicaid Agency. It is particularly relevant for medications that may require additional justification due to their cost or specific usage criteria.
The form must be completed by the prescribing practitioner, who is responsible for certifying that the treatment is necessary for the patient. Additionally, information about the patient, the dispensing pharmacy, and any relevant clinical details must be included. This collaborative effort helps ensure that all necessary information is provided for a thorough review.
Several key pieces of information are necessary for the Alabama 390 form. This includes:
Each section must be filled out accurately to avoid delays in the approval process.
The completed Alabama 390 form can be submitted via fax or mail. The designated fax number is (800) 748-0116, and it can also be mailed to the address provided on the form: P.O. Box 3210, Auburn, AL 36832-3210. It is advisable to keep a copy of the submitted form for your records.
Once the form is submitted, it will be reviewed by the Health Information Designs (HID) team. They will assess the request based on the provided information and supporting documentation. The request may be approved, denied, or modified. The reviewer will then sign the form and indicate the response date and time. You will be notified of the outcome, which is crucial for determining the next steps in the patient's treatment plan.