How to Fill Out Alabama Medicaid Prior Authorization Forms 342 and 369

To complete and submit an Alabama Medicaid prior authorization form, choose the correct form for the service (Form 342 for most medical services and durable medical equipment, Form 369 for prescription drugs, or a specialty form for things like dental, oxygen, or wheelchair requests), fill in the patient’s Medicaid ID, your provider identifiers, the diagnosis and procedure codes, and attach supporting clinical documentation. Then submit the package through the Alabama Medicaid Interactive provider portal, by fax, or by mail to the state’s fiscal agent. Response times run from 24 hours for pharmacy requests to seven calendar days for standard medical requests.

Pick the Right Form

Alabama Medicaid uses different forms depending on the service. Submit the wrong one and the request comes back without being reviewed.¹

Form 342 — Prior Review and Authorization Request. The general form for medical services and durable medical equipment.
Form 369 — Pharmacy Prior Authorization Request. The general form for outpatient drugs.
Form 343 — Dental prior authorization.
Form 360 — Oxygen therapy.
Form 384 — Wheelchair evaluation attachment, submitted with Form 342.
Form 386 — Wheelchair modification or repair, mandatory for those requests.
Form 389 — Opioid dependence treatment.
Form 390 — Miscellaneous requests including EPSDT and compounding.
Form 409 — Pharmacy override.
Form 471 — Prior authorization change request, not for pharmacy.
PHY-96-11 — Cochlear implant requests.

Condition-specific pharmacy forms exist for growth hormone therapy (Forms 410-A through 410-D and 411), hepatitis C antivirals (Form 415), smoking cessation (Form 470), and biological injectables (Form 373).² Radiology (CT, MRI, PET) and cardiology services are handled directly through the provider web portal with no paper form.¹

Download forms from the Alabama Medicaid website’s Prior Authorization Forms page or Pharmacy Forms and Criteria page. Use the current posted version. Outdated revisions are a routine reason requests get bounced.

What to Have Ready Before You Start

Gather everything before you open the form. Going back to hunt down a missing code or prescription mid-way through is where delays begin.

Patient and Provider Identifiers

You need the recipient’s full name, date of birth, and 13-digit Medicaid identification number. The ID always begins with “500” or “530.”³ On the provider side, you need your National Provider Identifier and tax identification number. The state cross-references the NPI against its enrollment files, so any mismatch triggers manual review or outright rejection.

Clinical Documentation

Every request needs ICD-10 diagnosis codes and the HCPCS or CPT procedure codes for the service or item being requested. Codes alone aren’t enough. Attach the clinical records that establish medical necessity: recent lab results, imaging reports, physical therapy evaluations, or specialist notes, depending on the service.

For durable medical equipment, Alabama Administrative Code Rule 560-X-13-.03 spells out what must come with the form: a completed and signed prescription or order from the prescribing provider, any applicable EPSDT or Patient 1st PMP referral form, and documentation justifying medical necessity.⁴ The DME provider cannot self-prescribe. For pharmacy, the published clinical criteria for each drug class live on the Pharmacy Forms and Criteria page. Review the criteria for your drug before submitting; it tells you exactly what documentation the reviewer expects.²

Filling Out Form 342 for Medical Services and DME

Enter the recipient’s Medicaid ID, name, and date of birth in the patient identification section. In the provider section, enter your NPI and billing information, and make sure the rendering provider and billing provider fields match what’s enrolled with the state.

In the clinical section, put the ICD-10 diagnosis code in the diagnostic justification area and the HCPCS or CPT procedure code for the requested service. Fill in the requested duration of treatment and the quantity of items or number of service units. Blank fields in these sections are the single most common reason forms come back marked incomplete.

Attach the supporting clinical notes as one package with the form. For DME, include the prescriber’s signed order or prescription.⁴ Wheelchair requests need Form 384 (evaluation) or Form 386 (modification or repair) attached to the Form 342.¹

Filling Out Form 369 for Pharmacy

Form 369 covers most outpatient drug prior authorizations. The practitioner initiates the request when the prescribed medication requires authorization under Alabama Medicaid’s formulary rules.⁵ Enter the drug name, strength, dosage, and quantity along with the patient’s diagnosis. The clinical criteria document published with Form 369 lists the specific approval requirements for each drug class: dosage limits, step therapy prerequisites, required lab values, and documentation of prior treatment failures.²

Approval windows vary by drug class. Most run up to 12 months per approval. Anxiolytics and sedatives start at three months for an initial request and six for renewals; growth hormone agents and CGRP antagonists typically top out at six months.⁶ Refills within an approved period don’t need a new request.

Where to Send It

Three channels are available. The web portal is fastest and, for radiology and cardiology, the only option.

Provider web portal. The Alabama Medicaid Interactive portal lets you upload requests and get electronic confirmation. For non-pharmacy requests, a field in the portal lets you mark the request as urgent. The agency monitors that field for overuse, so flag it only when the clinical situation genuinely requires faster review.⁷⁸
Online pharmacy PA system. Pharmacy requests can also be submitted at almedicaid.acentra.com.⁹
Fax or mail. Completed forms and attachments can be sent to the state’s fiscal agent.

One hard deadline for DME: the prior authorization request must reach the fiscal agent within 30 calendar days after the equipment is dispensed. Requests arriving after that window are denied.⁴

For pharmacy questions or to check status on a pharmacy PA, the toll-free line is (800) 748-0130, extension 2020.¹⁰

When You’ll Hear Back

Pharmacy prior authorizations are decided within 24 hours of receipt under federal law, and Alabama’s rules target eight hours but cap the response at 24. If a decision hasn’t come through and the patient needs the medication, the pharmacy must dispense at least a 72-hour emergency supply of a covered outpatient drug.¹¹

Non-pharmacy medical requests follow updated federal timeframes effective January 1, 2026. Standard requests receive a response within seven calendar days. Expedited requests, where delay could seriously jeopardize the patient’s life, health, or ability to function, receive a response within 72 hours.⁸ These align with 42 CFR 438.210, which shortened the standard window from 14 calendar days to 7 for rating periods starting on or after January 1, 2026. Either deadline can be extended by up to 14 additional calendar days if the provider or patient asks for the extension, or if the reviewer needs more information and can show the extension serves the patient’s interest.¹²

Approval notifications include a prior authorization number (ten digits for DME) and the timeframe during which the provider may dispense the equipment or service and bill for it.⁴ For DME, the letter sets a delivery deadline; if you can’t deliver in time, request an extension in writing with the reason for the delay. Status can be checked through the Alabama Medicaid Interactive portal alongside claims and eligibility.⁷

If the Request Is Denied

A denial notice goes to both the provider and the recipient. It states the specific reasons the request was rejected, usually insufficient clinical documentation or failure to meet the published medical criteria, and explains the right to appeal.⁴ A provider cannot bill the recipient for an item denied because of the provider’s own error or documentation failure.

For pharmacy denials, the prescriber can submit additional medical justification in writing. If the denial is overturned on that review, the authorization is granted.⁵

Recipients who want to contest a denial can request a fair hearing. The written request must reach Alabama Medicaid within 60 days from the date the denial notice was mailed; requests outside that window are not accepted.¹³ The hearing is scheduled at a time and place reasonably convenient for both sides, with written notice sent at least ten calendar days in advance.¹⁴

One Note on Emergencies

Prior authorization is not required for emergency medical screening and stabilization. Under EMTALA, any hospital emergency department that accepts Medicare must screen for emergency conditions and provide stabilizing treatment regardless of insurance status.¹⁵ For urgent prescriptions, the pharmacy’s 72-hour emergency supply rule covers the gap while a pharmacy PA is pending.¹¹

1
Alabama Medicaid. Prior Authorization Forms
2
Alabama Medicaid. Pharmacy Forms and Criteria
3
Legal Information Institute. Alabama Code r 560-X-1-.09 – Recipient Identification Number
4
Legal Information Institute. Alabama Code r 560-X-13-.03 – Method of Requesting DME
5
Alabama Medicaid Agency. Alabama Administrative Code Chapter 560-X-16 – Pharmaceutical Services
6
Alabama Medicaid. Preferred Drug and Prior Authorization Program
7
Alabama Medicaid. Alabama Medicaid Interactive
8
Alabama Medicaid. Changes to Non-Pharmacy Prior Authorization Process
9
AL Medicaid. Home
10
Alabama Medicaid. Alabama Medicaid Contacts
11
Social Security Administration. Social Security Act Section 1927
12
eCFR. 42 CFR 438.210
13
Alabama Administrative Code. Alabama Code r 560-X-3-.03 – Fair Hearing Procedures for Recipients
14
Alabama Administrative Code. Alabama Code Chapter 560-X-3 – Fair Hearings
15
Centers for Medicare & Medicaid Services. You Have Rights in an Emergency Room Under EMTALA