How to Fill Out the Alignment Health Plan Prior Authorization Form

The Alignment Health Plan prior authorization form is a one-page request your provider completes and sends to the plan before delivering a service, procedure, or Part B drug that needs advance approval. It collects the patient’s insurance details, diagnosis and procedure codes, and a description of the requested treatment so the plan’s clinical reviewers can decide whether the service meets coverage criteria. You can download it from Alignment’s provider page and submit it through the AVA Provider Portal, by fax, or by mail.¹

Where to Get the Form

The form is available as a downloadable PDF on Alignment Health Plan’s provider website. Contracted providers can also access it through the AVA Provider Portal at ava.alignmenthealth.com and fill it out electronically.¹ Non-contracted providers can reach the same PDF through the provider manual page.² Members who want to request a coverage determination on their own can use the plan’s separate determination request page, which lists mailing and fax information.³

What Goes on the Form

The form asks for two categories of information: identifying details and clinical justification. Mistakes in either are the fastest way to trigger a delay or denial.

Patient and Provider Identification

Enter the patient’s full legal name and date of birth exactly as they appear on the insurance card. A small mismatch, such as a middle initial on the card that is missing from the form, can cause an administrative rejection before anyone looks at the clinical information. Include the member identification number from the card, the provider’s National Provider Identifier (NPI), and the provider’s Tax Identification Number (TIN). These fields route the request to the right clinical team and link it to the correct billing account.

Diagnosis and Procedure Codes

The clinical section requires ICD-10 diagnosis codes that explain why the service is needed, paired with HCPCS or CPT codes that identify the exact service being requested. List every relevant diagnosis code, not just the primary one. If a patient needs a knee MRI because of both chronic pain and a suspected meniscal tear, including both codes gives the reviewer a fuller picture and reduces the chance of a follow-up request for more information.

Supporting Clinical Documentation

Attach the records that make the case: recent office visit notes, lab results, imaging reports, and any specialist consultation records. The strongest submissions tell a short clinical story. What is wrong, what has already been tried, and why this next step is appropriate. If earlier treatments failed or were inadequate, say so explicitly in the notes rather than leaving the reviewer to piece it together from scattered records. Federal regulations require Medicare Advantage plans to have procedures for timely decisions based on the enrollee’s benefit package, and reviewers evaluate the request against the plan’s coverage criteria and national coverage determinations.⁴ Complete documentation is the single biggest factor in whether a request sails through or stalls.

How to Submit It

Alignment Health Plan accepts prior authorization requests through three channels, and strongly encourages contracted providers to use the portal rather than fax or mail.¹

AVA Provider Portal (preferred). Log in at ava.alignmenthealth.com to submit outpatient (pre-service) and inpatient (admission) requests electronically. The portal generates a reference number on successful upload. Non-contracted providers can submit through avaprovidertools.alignmenthealth.com/authorizations without a full portal account.
Fax. Send the completed form and all supporting documentation to 1-800-693-6703. Include a cover sheet listing the total number of pages, and keep the transmission confirmation as proof of delivery.³
Mail. Send physical copies to Alignment Health Plan, Attn: Clinical Review Department, 2900 Ames Crossing Road, Eagan, MN 55121. Use certified mail or a tracked shipping method. Transit time counts against the decision clock, so mail works best for non-urgent requests.³

To check on a pending request by phone, the prior authorization department can be reached at 1-844-942-4226. The hospital admissions line is 1-844-361-4715.⁵

When You Will Get a Decision

Federal rules set maximum timeframes for Alignment Health Plan to respond, and those deadlines depend on what you asked for and how urgent it is.

Standard Requests

For items and services subject to the prior authorization rules in 42 CFR § 422.122, the plan must decide within 7 calendar days of receiving the request. That deadline took effect January 1, 2026, replacing the previous 14-day window. For items and services not subject to those specific rules, the older 14-calendar-day timeframe still applies. The plan can extend either timeframe by up to 14 additional calendar days if you request it, if the plan needs medical records from an outside provider that could change the outcome, or under other extraordinary circumstances. If an extension is granted, the plan must notify you in writing and explain the reason.⁶

For Part B drugs, meaning medications administered in a clinical setting such as infusion therapies, the plan must decide within 72 hours. That deadline cannot be extended.⁶

Expedited Requests

If waiting for a standard decision could seriously threaten your life, health, or ability to regain function, you or your provider can request expedited review. When a physician supports the request, the plan must grant expedited status.⁷ Under expedited review, the plan has 72 hours to decide on a medical service or item and 24 hours for a Part B drug.⁸

If the plan denies an expedited request, it automatically converts the case to a standard determination and must process it within the standard timeframe, starting from when it first received the expedited request rather than the date of the denial. The plan must notify you orally of the denial and follow up with a written letter within three calendar days explaining your right to file a grievance or resubmit with a physician’s support.⁷

Part D Prescription Drugs

If the request involves a retail prescription drug covered under the plan’s Part D benefit, as opposed to a Part B drug given in a medical setting, different regulations apply. The plan has 72 hours for a standard coverage determination and 24 hours for an expedited one.⁹¹⁰

If the Request Is Denied

A denial is not the end of the road. As of 2026, denial notices for covered items and services (other than prescription drugs) must include a specific reason rather than a generic “does not meet criteria” statement, which makes it easier to see what to address on appeal.¹¹

Ask the Plan to Reconsider

The first step is requesting a reconsideration from Alignment itself. You, your representative, or the provider who furnished the service can file. The request can be made in writing, and for pre-service denials sometimes orally. The plan reviews the original determination along with any new evidence you submit. For standard pre-service appeals, the plan generally has 30 calendar days to decide. For expedited appeals, the timeframe is 24 hours. Part B drug appeals must be resolved within 7 calendar days.¹² The standard timeframe can be extended by up to 14 calendar days if you request it or if the plan needs additional medical evidence from an outside provider.

Independent Review

If the plan upholds its denial on reconsideration, it must automatically forward your case to the Part C Independent Review Entity (IRE), currently MAXIMUS Federal Services, for an independent look. You do not need to file a separate request. The IRE’s decision deadlines mirror the plan-level ones: 72 hours for expedited requests, 30 calendar days for standard pre-service reviews, 7 calendar days for Part B drugs, and 60 calendar days for payment disputes.¹² If the IRE decision is also unfavorable, the written notice will explain how to request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals. Most prior authorization disputes are resolved before that stage.

How to Keep a Request Moving

Match the patient’s name and date of birth on the form character-for-character to the insurance card. Discrepancies cause administrative rejections before clinical review even begins.
Submit through the AVA Provider Portal when possible. It is faster than fax, eliminates the transit time of mail, and generates an instant reference number.
Attach everything up front. Piecemeal records give the plan grounds to extend the deadline. Bundling all clinical notes, lab work, and imaging with the initial submission keeps the clock on its original timeline.
Spell out failed alternatives. If the patient tried a less intensive treatment first and it did not work, say so in the clinical notes. A documented progression of care is far more persuasive than a bare diagnosis code.
Flag urgent requests clearly and include the physician’s statement explaining why a standard wait would jeopardize the patient’s health. Without that statement, the plan can deny expedited status and default to the standard timeframe.

1
Alignment Health Plan. Prior Authorization
2
Alignment Health Plan. Provider Manual
3
Alignment Health Plan. Determination Request
4
eCFR. 42 CFR 422.566 – Organization Determinations
5
Alignment Health Plan. Contact Us
6
eCFR. 42 CFR 422.568 – Standard Timeframes and Notice Requirements for Organization Determinations
7
eCFR. 42 CFR 422.570 – Expediting Certain Organization Determinations
8
eCFR. 42 CFR 422.572 – Timeframes and Notice Requirements for Expedited Organization Determinations
9
eCFR. 42 CFR 423.568 – Standard Timeframes and Notice Requirements for Coverage Determinations
10
eCFR. 42 CFR 423.572 – Timeframes and Notice Requirements for Expedited Coverage Determinations
11
eCFR. 42 CFR 422.122 – Prior Authorization
12
Centers for Medicare & Medicaid Services. Reconsideration by Part C Independent Review Entity (IRE)