Alabama Medical Billing and Payer Rules

Timely Filing in Alabama

Alabama and the Federal No Surprises Act

CMS found no Alabama law or All-Payer Model Agreement that sets the out-of-network rate, so the federal process applies to insured coverage.

Major Payers

How Does Alabama Medicaid Work for Billing?

Alabama's Medicaid program is run by the Alabama Medicaid Agency. Under Administrative Code rule 560-X-1-.06, the Agency contracts with a fiscal agent to process and pay all claims from providers of services authorized under the Alabama Title XIX State Plan, and providers with claim questions are told to contact that fiscal agent first.

The Agency's provider contacts page lists Gainwell Technologies, in Montgomery, as the contact for the Provider Assistance Center, provider enrollment, the electronic claims helpdesk and the secure web portal.

Claims are electronic. Rule 560-X-1-.17(1) says providers of services and supplies shall submit claims electronically, and claim form instructions sit in the provider manual posted on the Agency website.

Which Managed Care Programs Does Alabama Medicaid Run?

The Agency's managed care page says its managed care programs are the Alabama Coordinated Health Network (ACHN) and the Integrated Care Network (ICN) programs. The Agency says the ACHNs operate in seven regions.

The ACHN Administration page lists seven ACHN contracts: Alabama Care Network Mid-State, Alabama Care Network Southeast, Gulf Coast Total Care, My Care Alabama Central, My Care Alabama East, My Care Alabama Northwest and North Alabama Community Care. The ICN page says the ICN program was approved by CMS on September 12, 2018, serves most Medicaid long-term care beneficiaries, and uses the primary care case management entity model.

The sources cited here do not say how ACHN-related claims are routed, so confirm the route with Alabama Medicaid. Provider manual Chapter 40 covers ACHN and primary care physician billing, but the manual sits behind a license click-through, so we left its content off. Read it before you bill an ACHN entity.

How Do Enrollment and Revalidation Work?

The Agency's enrollment page says practitioners who prescribe, order or refer for Medicaid beneficiaries must be enrolled, and that providers revalidate when they are scheduled. A provider that fails to revalidate with the right documents gets an end date on its file, and once a file is closed the provider must submit a new application. Skilled nursing facilities are high or moderate risk, with a site visit at revalidation every 5 years.

ACHN providers must complete agreements with both Medicaid and the ACHN to receive bonus and participation rates. Enrollment contact is Gainwell at (888) 223-3630, Monday to Friday, 8 a.m. to 5 p.m. Central.

What Is the Alabama Medicaid Timely Filing Limit?

Alabama Medicaid pays only clean claims received by the fiscal agent within one year of the date of service. Rule 560-X-1-.17(3)(a) defines a clean claim as one that can be processed for payment or denied without more information from the provider, and a timely claim as a clean claim received by the fiscal agent within one year of the date of service, unless the Code sets a different limit.

A claim without enough information to enter the claims system is returned to the provider and does not count as submitted on time. A clean claim not timely received is denied as outdated, except under the exceptions below.

The retroactive eligibility and third-party rows are the ones that save money. A patient whose Medicaid is awarded months later gets a new one-year clock from the award notice, and the Agency FAQ says retro claims must be submitted electronically.

The recoupment window does not cover audits. Rule 560-X-1-.17(4)(c)1 calls claims recouped through medical record reviews or investigations, including Program Integrity and Recovery Audit Contractor reviews, final and not open to resubmission.

Rule 560-X-1-.17(5)(b) says a clean claim should normally get payment or denial within 30 days. If not, ask the fiscal agent for a status report, then write to the Medicaid associate director for the program before the time limit expires.

How Do You Challenge an Outdated Claim Denial with Alabama Medicaid?

Start with an administrative review, not a fair hearing. Rule 560-X-1-.17(6)(b) says a provider is not entitled to a fair hearing on an outdated claim until after an administrative review, and a hearing request received first is treated as a request for review.

1. Send a written request to the appropriate Medicaid program area, so that it is received within 60 days of the date the claim became outdated.
2. Include documentation of your good faith attempts to obtain payment, including copies of the relevant EOPs and your correspondence with the fiscal agent and Medicaid, as rule (6)(c) requires.
3. Include an error-free claim the fiscal agent can process if the decision is favorable.
4. If the review is denied, send a written fair hearing request that Medicaid receives within 60 days of the denial letter, under Chapter 3 of the Administrative Code.

The rule lets Medicaid tell the fiscal agent to waive the limit when the claim was originally filed before it became outdated and the provider made a good faith effort to file a clean claim. There is no further review when the reprocessed claim denies for a provider error.

Who Is the Medicare Contractor for Alabama?

Palmetto GBA, LLC is the Medicare Part A and Part B contractor for Alabama, in Jurisdiction J (JJ). The CMS list of MACs by state and the Palmetto GBA home page both show Jurisdiction J as AL, GA and TN.

The CMS PDF we used is dated March 2023. Medicare timely filing is one calendar year after the date of service under 42 CFR 424.44(a)(1). The Medicaid clock counts receipt by the fiscal agent and has its own exceptions. See the Medicare and Medicaid payer pages for the national picture.

Does Alabama Have a Prompt Pay Law?

Yes. Ala. Code 27-1-17 requires insurers, health service corporations and health benefit plans that issue or renew accident or health policies to pay for services rendered by Alabama health care providers within 45 calendar days of a clean written claim or 30 calendar days of a clean electronic claim.

A plan that denies or pends the claim must say why, and what extra information it needs, within the same 45 or 30 days. After it gets that information it has 21 calendar days to pay, deny or adjudicate. Undisputed portions follow the same schedule.

A claim that is overdue carries interest of 1.5 percent per month, prorated daily, from the date payment was overdue, payable when the claim is paid. If the plan never sent the denial or pending notice, interest runs from the date that notice should have gone out.

The Commissioner may fine a plan up to $1,000 per violation of subsections (e), (f) and (g), or per day claims stay unpaid, to a maximum of $100,000 per violation. The Department's complaint page says it cannot assist medical providers, so send the plan a written demand citing the section and the interest owed.

Does Alabama Have Its Own Surprise Billing Law?

No state surprise billing law was identified for Alabama. In its December 8, 2021 letter to the Governor and Insurance Commissioner, CMS says Alabama has no applicable All-Payer Model Agreement and did not identify in its survey response any state law governing the out-of-network rate. The letter concludes that federal IDR applies for insured group and individual coverage in Alabama.

The same letter says CMS understood Alabama lacked authority to enforce several No Surprises Act provisions, so CMS enforces them directly there. Plans and issuers continue to use the federal external review process, and the federal patient-provider dispute resolution process applies to uninsured or self-pay patients.

• The out-of-network rate for emergency services, and for non-emergency services at in-network facilities, comes from an agreed amount or from federal IDR, not a state formula.
• Open negotiation lasts 30 business days, starting on the day the provider gets the initial payment or denial, under 45 CFR 149.510(b).
• Federal IDR is started by written notice in the 4 business days that begin on the first business day after open negotiation ends, under 45 CFR 149.510(c).

The letter is from 2021, and this page cites no newer one or any Alabama statute. The state surprise billing laws guide tracks which states differ.

What About Self-Funded Employer Plans?

The Alabama Department of Insurance says it cannot help with plans not subject to Alabama insurance law, and that for a self-funded plan the employer administers the program. It also says it cannot determine the amount of money owed on a claim or assist medical providers. Those disputes run through negotiation, IDR or the plan appeal process.

Which Payers Matter in Alabama?

We name only payers shown to operate in Alabama by official sources. Alabama Department of Insurance releases of August 29 and October 17, 2025 name the four carriers in the state's individual ACA market for 2026: Blue Cross Blue Shield of Alabama, UnitedHealthcare Insurance Company, Celtic Insurance Company and Oscar Insurance Company, with Oscar new in 2026.

These are the individual-market carriers only. This page cites no Department report ranking group carriers, so it gives no market share and names no other payer.

How We Handle Billing in Alabama

For Alabama clients we sort every account into its claim path first: Gainwell for Medicaid, Palmetto GBA for Medicare, and the insurer for commercial plans, each with its own clock. Claims go out within 24 hours of charge entry, and denials are worked within 48 hours.

We flag late Medicaid awards against the award notice date and track the 120 day window from a Medicare or other payer notice date. We start with eligibility checks and use the out-of-network billing and IDR service for emergency and facility disputes, while the hospital and facility billing service covers UB-04 claims.

To review your Alabama payer mix and filing clocks, book a call.