Form 471 - Prior Authorization (Pa) Change Request
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1Alabama Medicaid Agency
Prior Authorization (PA) Change Request
Supplier Information
Contact Name:
NPI:
Phone Number:
Recipient Information
Recipient Name:
Medicaid ID:
Prior Authorization Number
Reason for Change
Please use this section to denote what field(s) on the PA request require a change.
Complete all applicable fields below.
Examples: Add/Change Modifier: Add “RR” to “E1088”
Correct Date(s) of Service: Change requested effective date from 08/01/2010 to 10/01/2010
Add/Change Modifier:
Correct Number of Service(s):
Correct Place of Service:
Correct Diagnosis Code(s):
Correct Date(s) of Service:
Correct NPI:
Other: (Please Explain)
Comments
NOTE: The Alabama Medicaid Agency cannot revise a PA for which a claim has already been paid. The
paid claim must be voided before the PA can be changed. This form must be received within 90 days of
the date of the approval on the PA decision letter. The form is to be used for PA requests in
evaluation status or for simple changes to an approved PA, such as adding appropriate modifiers.
The form is NOT to be used for reconsiderations of denied PAs; for procedure code changes
, or
for pharmacy PAs.
For DME, surgical, vision, ambulance and PDN PAs ONLY, fax to (888) 213 – 8548 (Qualis
•
Health)
For dental PAs, fax to: 334-353-3426
•
For radiology, or cardiology related PAs, fax to: (334) 242-0533
•
Form 471
Alabama Medicaid Agency
Revised: 09/30/2016
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Parent category: Medical