PAYER POLICY CHANGES

Alabama Medicaid Policy Changes

Policy changes from Alabama Medicaid and from Medicaid managed care plans in Alabama, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.

Alabama Medicaid · Effective Feb 1, 2027Medium impact
Changes in Billing Procedures for Certified Registered Nurse Practitioners
Effective February 1, 2027, Certified Registered Nurse Practitioners (CRNPs) providing Rural Health Clinic services must bill with their individual NPI in the rendering provider ID field (Block 24J) of the CMS-1500 claim form. CRNPs affiliated with rural health clinics must be enrolled with an NPI linked to the clinic under provider type 58 – Rural Health Clinic, and those not yet enrolled with Alabama Medicaid should apply through the Electronic Provider Enrollment Application Portal.
Alabama Medicaid · Effective Jun 30, 2026Medium impact
New Cost Report Submission Portal and Portal Account Access
Alabama Medicaid is transitioning all hospital cost report submissions to a new secure web portal hosted by Myers and Stauffer, effective June 30, 2026. Hospital providers must complete and submit a registration form by November 15, 2026, to gain portal access before the November 30, 2026 cost report deadline.
Alabama Medicaid · Identified Oct 30, 2026High impact
CMS-0056-F Pharmacy Standards Compliance Update, CMS-4205-F2 and Readiness Notice
CMS is implementing federal pharmacy standards updates (CMS-0056-F) requiring Alabama Medicaid and all pharmacy trading partners to adopt new NCPDP and HIPAA transaction standards for formulary exchange, e-prescribing, claim adjudication, and eligibility verification. Compliance occurs across multiple dates from January 2027 through April 2028, with D.0 transaction processing ending on April 14, 2028. Pharmacies must coordinate with software vendors and trading partners to meet each standard's deadline.
Alabama Medicaid · Effective Oct 23, 2026Medium impact
New Prior Authorization Web Portal Attachment Panel Enhancements
Alabama Medicaid has enhanced its Prior Authorization Web Portal Attachment Panel with new features effective October 23, 2026, including on-screen documentation reminders, conditional submitter contact information requirements (only when files are uploaded), a 20-line item limit, automatic NIPT section display, and barcode coversheet generation for faxed documents. These changes apply to non-pharmacy prior authorizations.
Alabama Medicaid · Effective Jul 1, 2026Medium impact
New Justice-Involved Youth (JIY) Travel Payment for EPSDT Provider’s Travel to Carceral Facilities
Alabama Medicaid introduces a new $50 travel payment (CPT 99429) for EPSDT providers delivering screenings to justice-involved youth in carceral facilities, effective July 1, 2026. The payment is in addition to the existing $88 EPSDT screening rate, with a limit of two payments per calendar year per beneficiary. Providers must use POS code 09 and be enrolled with Specialty 560 to bill this service.
Alabama Medicaid · Effective Oct 24, 2026Low impact
Important Alabama Medicaid Systems Access – October 24, 2026
Alabama Medicaid systems will undergo planned network maintenance on October 24, 2026, from 9:00 a.m. to 12:00 p.m., causing temporary unavailability of multiple online applications and portals. The Eligibility and Claims systems will remain available during this maintenance window.
Alabama Medicaid · Effective Oct 1, 2026Medium impact
Coverage Update – Hearing Evaluation
Alabama Medicaid updated coverage requirements for hearing evaluations effective October 1, 2026. Licensed physicians must now complete hearing evaluations within six (6) months prior to hearing aid fitting. Audiology providers must ensure all hearing aid services submissions comply with this updated timeline requirement per Alabama Administrative Code Rule No. 560-X-19-.01.
Alabama Medicaid · Effective Nov 1, 2026High impact
Removal of Prior Authorization Requirements for Radiology and Cardiology Procedures
Effective November 1, 2026, Alabama Medicaid will remove prior authorization requirements for MRI, MRA, CT, CTA, PET scans, nuclear cardiology services, diagnostic heart catheterizations, and stress echocardiography procedures. Prior to this date, providers must continue obtaining PA before furnishing these services; claims submitted without approved PA will be denied.
Alabama Medicaid · Effective Jan 1, 2027High impact
Changes to Maternity Care CPT Codes for 2027
Alabama Medicaid is retiring global maternity care CPT codes effective January 1, 2027, and replacing them with new AMA-established codes. Providers must use existing global codes for services delivered in 2026 and new maternity codes (with TH modifier) for services on or after January 1, 2027. For split-year cases where prenatal care occurs in 2026 but delivery is in 2027, billing will use two different code sets based on service date.
Alabama Medicaid · Effective Oct 1, 2026High impact
Removal of Medicare and TPL Exemption
Effective October 1, 2026, Alabama Medicaid is removing the exemption that allowed optometrists and opticians to file claims directly with Medicaid. Providers must now file with the beneficiary's primary insurance (including Medicare) before submitting claims to Medicaid. This represents a shift to mandatory primary-secondary claim filing sequencing.
Alabama Medicaid · Effective Sep 26, 2026Low impact
Total Gainwell System Outage for MMIS Scheduled Maintenance COMPLETE
The Gainwell Technologies MMIS (Medicaid Management Information System) scheduled maintenance has been completed as of 9/26/2026, and all systems are now fully operational. Medicaid providers can resume normal claims submission and system access. This is a restoration notice confirming system availability after a planned outage.
Alabama Medicaid · Effective Sep 25, 2026High impact
Total Gainwell System Outage for MMIS – Scheduled Maintenance
The Gainwell Technologies MMIS system will be completely unavailable for scheduled maintenance from September 25-28, 2026. During this outage, all Medicaid claims submission, prior authorization requests, eligibility verification, and portal access will be offline. The Eligibility system (CARES) will remain available. Billing teams must plan ahead and avoid submitting claims during this window.
Alabama Medicaid · Effective Oct 1, 2026High impact
Preferred Drug List (PDL) and Pharmacy Quarterly Update
Effective October 1, 2026, Alabama Medicaid is removing DAW Code 9 (brand-only dispensing) from four drugs (Daytrana, Farxiga, Ravicti, Vyvanse capsules) while simultaneously requiring prior authorization for their generic equivalents and four other generics. Brand versions of Arnuity Ellipta, Cipro HC, Incruse Ellipta, and Zylet will retain preferred status with DAW Code 9. The PDL is being updated with quarterly additions and deletions, and pharmacy providers must ensure proper use of OCC and DAW codes to avoid claim recoupments during routine audits.
Alabama Medicaid · Effective Oct 1, 2026High impact
DME Program Quarterly Updates
Alabama Medicaid DME program implements four key updates: (1) updated prosthetics/orthotics provider enrollment criteria effective October 1, 2026; (2) Augmentative Communication Devices (ACDs) can now be delivered to speech language pathologists for setup/training with required delivery ticket documentation effective July 1, 2026; (3) new ACD coverage criteria checklist published; and (4) tracheostomy/laryngectomy tube benefit limits updated to 6 per calendar year for adults (A7520, A7521) effective October 1, 2026, with no change to pediatric limits. Policy also reinforces existing reminders on non-covered shipping charges, prior authorization requirements with valid prescriptions, and proper HCPCS coding.
Alabama Medicaid · Effective Sep 25, 2026High impact
Total Gainwell System Outage for MMIS – Scheduled Maintenance
The Gainwell Technologies MMIS system will undergo scheduled maintenance resulting in a complete outage from Friday, September 25, 2026 at 6:00 p.m. (non-pharmacy) / 9:00 p.m. (pharmacy) through Monday, September 28, 2026 at 6:00 a.m. Central Time. During this period, all claims submission, eligibility verification, prior authorization, and portal access will be unavailable. The CARES eligibility system will remain operational.
Alabama Medicaid · Effective Oct 1, 2026High impact
Alabama Medicaid DME and POP Provider Enrollment Requirements
Effective October 1, 2026, Alabama Medicaid is eliminating the state licensing requirement for DME and POP providers previously issued by the Alabama State Board of Prosthetists and Orthotists (which ceases operations September 30, 2026). All DME and POP providers must now be enrolled with Medicare and maintain Medicare accreditation and certification as the condition for Medicaid enrollment and revalidation. Providers will be assigned specialties based on their Medicare PECOS enrollment.
Alabama Medicaid · Effective Sep 1, 2026Medium impact
New Long-Term Care (LTC) Web Portal Admission Notification Panel
Alabama Medicaid has launched a new Long-Term Care (LTC) Web Portal Admission Notification Panel effective 9/1/2026, providing a streamlined, web-based alternative to current LTC admission notification software. This new portal is available at no charge to Type 3 (Nursing Homes/Hospital Swing Beds), Type 68 (PACE), and Type 53 (Waiver) providers, offering improved data validation, faster processing, and reduced administrative burden for LTC admission submissions.
Alabama Medicaid · Effective Sep 25, 2026High impact
Total Gainwell System Outage for MMIS – Scheduled Maintenance
The Gainwell Technologies MMIS system will undergo complete scheduled maintenance from Friday, September 25, 2026 at 6:00 p.m. CT (9:00 p.m. CT for pharmacy) through Monday, September 28, 2026 at 6:00 a.m. CT, making all claims submission, eligibility verification, prior authorization, and provider portal access unavailable. The Eligibility system (CARES) will remain operational during this outage.
Alabama Medicaid · Effective Aug 22, 2026Low impact
Planned Alabama Medicaid System Maintenance – August 22, 2026
Alabama Medicaid will conduct planned system maintenance on August 22, 2026, from 8:00 a.m. to 6:00 p.m., causing intermittent outages and temporary unavailability of multiple online portals and applications. However, the critical Eligibility and Claims systems will remain available throughout the maintenance window, so billing operations should not be disrupted.
Alabama Medicaid · Effective Oct 1, 2026High impact
Alabama Medicaid DME and POP Provider Enrollment Requirements
Alabama Medicaid is eliminating the state Board of Prosthetists and Orthotists licensing requirement effective October 1, 2026. DME and POP providers must now enroll with Medicare and maintain Medicare accreditation/certification as the new condition for Medicaid enrollment and revalidation, replacing the previous state license requirement.
Alabama Medicaid · Effective Jul 24, 2026Medium impact
Planned Alabama Medicaid System Maintenance - July 24–26, 2026
Alabama Medicaid will conduct planned system maintenance from July 24–26, 2026, affecting multiple online portals and applications. The Eligibility and Claims systems will remain available during this window, but providers should be aware that several portals will be temporarily unavailable, potentially impacting access to estate notices, expedited services, and other administrative functions.
Alabama Medicaid · Effective Jan 1, 2026Medium impact
Coverage Update
Alabama Medicaid added coverage for 9 audiology procedure codes (CPT 92631-92639, 92641) effective January 1, 2026, covering hearing aid selection, fitting, post-fitting follow-up, and verification services. Coverage is limited to eligible Medicaid beneficiaries ages 0-20 years, and no prior authorization is required.
Alabama Medicaid · Effective Jul 7, 2026Medium impact
ACA Safe Harbor Outage – Scheduled Maintenance
ACA Safe Harbor will experience scheduled maintenance on Tuesday, July 7, 2026, from 12:00 a.m. to 5:00 a.m. Central Time, during which real-time and batch 270/271 and 276/277 eligibility and claims status transactions will be unavailable. Provider Web Portal file transmission and claims submission will not be affected. Billing teams should plan workflow around this 5-hour outage window.
Alabama Medicaid · Effective Jun 30, 2026High impact
Alabama Medicaid 2026 Off-Cycle Revalidation
Alabama Medicaid is conducting off-cycle provider revalidations effective 6/30/2026, with two tracks: swift revalidation for high-risk providers (DME, Home Health, Hospice, Nursing Facilities, ABA, Behavioral Health) and 24-month revalidation for moderate/limited-risk providers (33 provider types including hospitals, physicians, pharmacies, clinics). Providers will receive phased revalidation notices and must respond timely via the Medicaid Secure Web Portal or face enrollment termination.
Alabama Medicaid · Effective Jul 1, 2026High impact
Preferred Drug List (PDL) and Pharmacy Quarterly Update
Alabama Medicaid is implementing a quarterly PDL update effective July 1, 2026, adding three new preferred drugs (Starjemza, Wegovy, Yesintik) and removing four drugs (Aricept, Combivent Respimat, Epclusa, Harvoni). The policy removes DAW Code 9 from Elidel, discontinues posting alphabetical PDL documents, and emphasizes strict audit compliance for OCC-3 and DAW-8 code usage with required supporting documentation to avoid claim recoupments.
Alabama Medicaid · Effective May 1, 2026Low impact
Elimination of the Out of State Hospital Update Form
Alabama Medicaid is eliminating the Out-of-State Hospital Update Form effective May 1, 2026. All hospital providers will now receive 5-year enrollment periods but will be purged if they don't have paid claims within 24 months. Currently active out-of-state hospitals must complete revalidation by the end of their current 6-month extension.
Alabama Medicaid · Effective May 18, 2026Medium impact
Applied Behavior Analysis Providers
Alabama Medicaid now requires that beneficiaries must be evaluated and diagnosed with an ABA-eligible diagnosis by qualified practitioners (licensed psychologists, psychiatrists, or pediatricians) before receiving Applied Behavior Analysis services. A program update meeting is scheduled for June 15, 2026.
Alabama Medicaid · Effective May 21, 2026Medium impact
Provider Secure Web Portal Outage – Scheduled Maintenance
The Provider Secure Web Portal operated by Gainwell will be unavailable for scheduled maintenance from Thursday May 21, 2026 at 11:59 PM through Friday May 22, 2026 at 5:00 AM Central Time. During this outage, providers cannot access the portal for claims submission, processing, eligibility verification, or related transactions.
Alabama Medicaid · Effective May 21, 2026Low impact
Provider Secure Web Portal Outage – Scheduled Maintenance Cancelled
The previously scheduled maintenance for the Provider Secure Web Portal on May 21-22, 2026 has been cancelled. The portal will remain fully operational during the originally scheduled timeframe with no outage occurring.
Alabama Medicaid · Effective Jun 5, 2026High impact
Alabama Medicaid 2026 Off-Cycle Revalidation
Alabama Medicaid is conducting mandatory off-cycle revalidation for all providers in 2026, with high-risk providers (DME, Home Health, Hospice, Nursing Facilities, ABA Therapy, Behavioral Health) requiring swift revalidation and all other provider types requiring 24-month revalidation. Providers will receive phased revalidation notices and must complete required forms through the Medicaid Secure Web Portal.
Alabama Medicaid · Effective Jul 1, 2026Medium impact
Prior Authorization Requirements for 2026 Radiology CPT Codes
Alabama Medicaid will require prior authorization for two specific CT scan procedures (head/neck blood vessels and brain blood flow with contrast) starting July 1, 2026. Claims submitted without approved prior authorization will be denied.
Alabama Medicaid · Effective Jul 1, 2026High impact
Applied Behavioral Analysis Therapy Diagnostic Requirements
Effective July 1, 2026, Alabama Medicaid requires pediatricians to obtain a special ABA Specialty 175 designation before they can make autism diagnoses for ABA therapy referrals. Without this specialty designation, all ABA therapy referrals from pediatricians will be denied, and nurse practitioners can no longer diagnose autism for ABA referrals.
Alabama Medicaid · Effective Oct 1, 2026Medium impact
Reminder of Patient-Centered Medical Home (PCMH) Recognition Attestation Deadline
Alabama Medicaid is reminding Primary Care Physician groups participating in the Alabama Coordinated Health Network (ACHN) that Patient-Centered Medical Home (PCMH) recognition attestations for Fiscal Year 2027 must be submitted by October 1, 2026. All PCP groups must attest regardless of which certifying entity provided their PCMH recognition.
Alabama Medicaid · Identified Jun 21, 2026Medium impact
Follow-Up to June 15, 2026 ALERT - Applied Behavioral Analysis Therapy Diagnostic Requirements
Alabama Medicaid has paused the implementation of new Applied Behavioral Analysis (ABA) therapy diagnostic requirements that were set to take effect July 1, 2026. The agency will provide additional guidance and clarity on these requirements at a later date.

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Changes in Billing Procedures for Certified Registered Nurse Practitioners

New Cost Report Submission Portal and Portal Account Access

CMS-0056-F Pharmacy Standards Compliance Update, CMS-4205-F2 and Readiness Notice

New Prior Authorization Web Portal Attachment Panel Enhancements

New Justice-Involved Youth (JIY) Travel Payment for EPSDT Provider’s Travel to Carceral Facilities

Important Alabama Medicaid Systems Access – October 24, 2026

Coverage Update – Hearing Evaluation

Removal of Prior Authorization Requirements for Radiology and Cardiology Procedures

Changes to Maternity Care CPT Codes for 2027

Removal of Medicare and TPL Exemption

Total Gainwell System Outage for MMIS Scheduled Maintenance COMPLETE

Total Gainwell System Outage for MMIS – Scheduled Maintenance

Preferred Drug List (PDL) and Pharmacy Quarterly Update

DME Program Quarterly Updates

Total Gainwell System Outage for MMIS – Scheduled Maintenance

Alabama Medicaid DME and POP Provider Enrollment Requirements

New Long-Term Care (LTC) Web Portal Admission Notification Panel

Total Gainwell System Outage for MMIS – Scheduled Maintenance

Planned Alabama Medicaid System Maintenance – August 22, 2026

Alabama Medicaid DME and POP Provider Enrollment Requirements

Planned Alabama Medicaid System Maintenance - July 24–26, 2026

Coverage Update

ACA Safe Harbor Outage – Scheduled Maintenance

Alabama Medicaid 2026 Off-Cycle Revalidation

Preferred Drug List (PDL) and Pharmacy Quarterly Update

Elimination of the Out of State Hospital Update Form

Applied Behavior Analysis Providers

Provider Secure Web Portal Outage – Scheduled Maintenance

Provider Secure Web Portal Outage – Scheduled Maintenance Cancelled

Alabama Medicaid 2026 Off-Cycle Revalidation

Prior Authorization Requirements for 2026 Radiology CPT Codes

Applied Behavioral Analysis Therapy Diagnostic Requirements

Reminder of Patient-Centered Medical Home (PCMH) Recognition Attestation Deadline

Follow-Up to June 15, 2026 ALERT - Applied Behavioral Analysis Therapy Diagnostic Requirements