The Alabama 390 form is a request form used to obtain prior authorization for certain medications under the Alabama Medicaid program. This form is essential for healthcare providers seeking approval for specific drug treatments, ensuring that patients receive necessary medications while adhering to state guidelines. If you need to fill out the Alabama 390 form, please click the button below.
The Alabama 390 form plays a crucial role in the Medicaid system, specifically addressing the needs of patients requiring pharmacy services. This form is designed for healthcare providers to request prior authorization for medications that may not be readily available under Alabama Medicaid guidelines. It captures essential patient information, including the patient's name, Medicaid number, and date of birth, ensuring that the request is associated with the correct individual. Additionally, it requires details from the prescribing practitioner, such as their name, National Provider Identifier (NPI), and contact information, affirming their commitment to supervise the patient's treatment. The form also includes sections for the dispensing pharmacy, allowing for clear communication between all parties involved. Critical to the approval process are the drug and clinical information sections, where healthcare providers must provide specific details about the requested medication, including quantity, diagnosis codes, and any necessary medical justifications. For compounded medications, the form further requires a breakdown of ingredients and compounding time, ensuring that all aspects of the request are thoroughly documented. By facilitating the necessary approvals, the Alabama 390 form ultimately aims to enhance patient care while adhering to Medicaid's regulatory framework.
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The Alabama 390 form is a request form used for prior authorization in the Medicaid pharmacy program. Along with this form, there are several other documents that may be needed to ensure a smooth process. Below is a list of commonly used forms and documents that can accompany the Alabama 390 form.
Having these forms and documents ready can help streamline the approval process for medication requests. Always ensure that all information is accurate and complete to avoid delays.
Completing the Alabama 390 form requires careful attention to detail. This form is essential for requesting prior authorization for certain medications through Alabama Medicaid. Below are the steps to ensure accurate submission.
Once the form is completed, it can be faxed to (800) 748-0116 or mailed to P.O. Box 3210, Auburn, AL 36832-3210. Ensure all information is accurate to avoid delays in processing.
Understanding the Alabama 390 form is crucial for healthcare providers and patients alike. However, several misconceptions can lead to confusion. Here are four common misconceptions:
In reality, this form is used for both initial requests and renewals. Whether a patient is starting a new medication or continuing an existing treatment, the Alabama 390 form is necessary to ensure proper documentation and approval.
While the prescriber must sign the form, anyone involved in the patient's care can assist in gathering the required information. This includes pharmacists and nursing home staff who can facilitate the submission process.
This is not the case. Certain fields, such as patient information and drug details, are mandatory. Incomplete forms may lead to delays in processing requests, so it is essential to provide all required information.
Submission of the form does not guarantee that the request will be approved. Each request is reviewed based on medical necessity and adherence to guidelines set by the Alabama Medicaid Agency. Approval is determined after careful evaluation by the reviewer.
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