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Al form 357 plan application medicaid program download 2025

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The document is an application form for the Alabama Medicaid Plan First Program, which provides family planning services to females aged 19-55 and males aged 21 and older (for vasectomies only). It includes sections for personal information, income details, health insurance coverage, and consent for information release. The form emphasizes the importance of accurate information and outlines the consequences of false statements.

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What is the claim form for Medicaid in Alabama?

Alabama recognizes two standard claim forms (UB-04 and CMS-1500) and three Medicaid non-standard claim forms (Pharmacy, Dental, and one Medicare/Medicaid-related claim form). The providers provider type determines which claim type to bill, as illustrated in the table below.

Does Alabama Medicaid accept paper claims?

Claims Submission Methods In some cases, a provider may have to file a claim on paper, for example, an administrative review or a commercial insurance denies a claim. Claims filed on paper must be submitted on a CMS-1500 claim form.

What documentation is required for Medicaid in Alabama?

To qualify for Medicaid, applicants must meet income, age or other requirements; provide proof of income and other information, fill out forms correctly and turn in a completed application to the correct office or worker. For more help, applicants should contact 1-800-362-1504.

What is the income limit for the Medicaid waiver program in Alabama?

The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases annually in January. In 2025, an applicant, regardless of marital status, can have a monthly income up to $2,901.

What is the claim form for Medicaid health insurance?

The CMS-1500 form is the official standard Medicare and Medicaid health insurance claim form required by the Centers for Medicare Medicaid Services (CMS) of the U.S. Department of Health Human Services.

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Does Alabama Medicaid pay for dental work?

Dental services must be provided by licensed dentists enrolled as Medicaid dental providers. Most adults age 21 and older are not eligible for dental coverage through Medicaid. However, pregnant recipients with maternity coverage have dental coverage through 60 days postpartum.

What paperwork do you need for Medicaid?

Proof of date of birth (e.g., birth certificate) Proof U.S. citizenship or lawful residence (e.g., passport, drivers license, birth certificate, green card, employment authorization card) Proof of all types of income, earned and unearned (e.g., paycheck stubs, retirement benefits, Supplemental Security Income)

Al form 357 plan application medicaid program download 2025

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What is the claim form for Medicaid in Alabama?

Does Alabama Medicaid accept paper claims?

What documentation is required for Medicaid in Alabama?

What is the income limit for the Medicaid waiver program in Alabama?

What is the claim form for Medicaid health insurance?

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Does Alabama Medicaid pay for dental work?

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