Medicaid Grievances and Requests (Alabama Medicaid Agency)

Sarika Ram filed this request with the Alabama Medicaid Agency of Alabama.


From: Connor Sheets

To Whom It May Concern:

Pursuant to the Alabama Public Records , I hereby request the following records:

Copies of the following completed forms received by the Alabama Medicaid Agency between January 1, 2017 and January 1, 2018:
-Form 393 (Grievance Form for complaints about Patient 1st providers)
-Form 401 (Request for Medical Utilization Redetermination First Appeal)
-Form 402 (Request for Medical Utilization Redetermination Second Appeal)
-Form 403 (Request for NCCI Administrative Review)
-Form 404 (Request Review of Outdated Medicaid Claim)

Please provide materials on a rolling basis, as they become available.

The requested documents will be made available to the general public, and this request is not being made for commercial purposes.

In the event that there are fees, I would be grateful if you would inform me of the total charges in advance of fulfilling my request. I would prefer the request filled electronically, by e-mail attachment if available or CD-ROM if not.

If you have any questions, please feel free to clarify via phone at 617-299-1832.

Thank you in advance for your anticipated cooperation in this matter.

I look forward to receiving your response to this request within 10 business days.


Connor Sheets

From: Alabama Medicaid Agency

Mr. Sheets,

The Alabama Medicaid Agency (Medicaid) is in receipt of your request for the following forms: 393, 401, 402, 403 and 404. As an agency of the State of Alabama, Medicaid is subject to the Alabama Open Records Act, Section 36-12-40 of the Code of Alabama 1975. The Alabama Open Records Act provides every citizen of the State of Alabama with access to the public writings of the State. Based on your request, it does not appear you are a citizen of the State of Alabama, and therefore, your request for public records is denied. However, please note that the forms you have requested are readily available in the "Forms Library" under the "Resources" tab on Medicaid's website.

Thank you,

DeeDra Wheeler
Administrative Procedures Office
Office of General Counsel
Alabama Medicaid Agency
P.O. Box 5624
501 Dexter Avenue
Montgomery, Alabama 36103
334-353-4476 (Telephone)
334-353-3907 (Fax)

[Alabama Medicaid Agency]<>[alabamasealgif]

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