Claims
• Comments/Suggestions for the Claims Department – Providers can use this form to send comments or suggestions to the Alliance Claims Department.
• Procedure Reimbursements Rates – Providers can use this form to request reimbursement information by identifying procedure codes.
• Interested in Electronic Claims Submission? – This form begins the electronic claims submission process.
• Telecommunications Provider and Biller Application/Agreement - Electronic Claim Submission - 837 file format – This application is used by providers in order to apply for electronic claims submission
• Telecommunications Provider and Biller Application/Agreement - Electronic Remittance Advice - 835 file format – This application is used by providers in order to apply for electronic remittance advice receipt. The 835 format is used to transmit claims processed by the Alliance to the provider or their clearinghouse for input into their Accounts Receivable system.
Finance
• Identification of an Overpayment – This form can be used to communicate an overpayment to the Alliance.
• Credit Balance Report – This form needs to be filled out quarterly and sent to the Alliance.
• OHC Referral Form – This form needs to be filled out for a member's Other Health Coverage.
Health Services
• Authorization Inquiry Form – This form is used by providers to check if a CPT code(s) requires a Treatment Authorization Request.
• Request for Administrative Member Classification – This form is used by providers requesting that an Alliance member be made an administrative member
• Consent for Sterilization or Hysterectomy Sample Form – This is a sample form to obtain consent for sterilization or a hysterectomy. Offices can feel free to duplicate this form and add their letterhead.
• Asthma Action Plan, English or Spanish – This form is used by providers participating in the Quality Based Incentive for Asthma Management. FAX form to (831) 430-5851 attn: Health Services Administrative Assistant.
• Medication Agreement, English or Spanish – This form may be used by providers participating in the Quality Based Incentive for Chronic Pain Management. FAX form to (831) 430-5851 attn: Health Services Administrative Assistant.
• Advance Directives Form, English or Spanish – This free advance directives form is easy for patients to read and understand.
• Staying Healthy Assessment Order Form – Use to order bulk quantities of the Staying Healthy Assessment forms and patient handouts. To print Staying Healthy forms and handouts yourself, go to the Staying Healthy Assessment page for .pdf versions in seven languages.
• Health Education Materials Order Form – Use to order free patient education materials on asthma and diabetes. See form for titles currently available.
• Medical Records Forms
Member Services
• Member Complaint Packet – This file can be printed out and handed to members who are interested in filing a complaint to the Alliance’s Grievance Coordinator. This file contains both English and Spanish versions of the Frequently Asked Questions and Member Rights and Complaint Form.
• Need Help with Your HMO? (English and Spanish) – Flyers from California Department of Managed Health Care describing how members can get help regarding their health plan.
Provider Services
• Instructions/Forms - Deletion of Patient From Case Management List
Instructions on how to complete and submit the “Request for Deletion of Patient from Case Management List” form.
• Member Appointment No-Show Notification – This form is used to inform Member Services that an Alliance member did not keep a scheduled appointment.
• Patient Complaint / Grievance Tracking Log – Form that Physicians/Providers can use to track patient requests for Complaint / Grievance Forms.
• Provider Dispute Form – This form is used by provider to file a dispute with the Alliance.
• Procedure Reimbursement Rates – This form is used by provider to request reimbursement rates information from the Alliance.
• Provider Eligibility Verification FAX Form – This form is used to FAX the member’s name, and date of birth, or the member’s Alliance ID or Social Security Number (Please note that the SSN can only be used to verify eligibility for Alliance Medi-Cal or Alliance Care IHSS members only), the date of service that you are checking eligibility for. The Alliance will fax you back the form indicating whether or not the member is/was eligible, what plan the member is/was enrolled in and who the PCP is/was.
• Provider Information Change Form – This form is used to update contact and practice information. Information includes provider address, phone number, contact information, payment address, and tax ID number.
• Provider Applications – If you are interested in becoming an Alliance provider, visit our Joining our Network page.
• Certification Regarding Lobbying - Exhibit D(F) Att 1 and 2 – If payments to provider under the Services Agreement are $100,000 or more, provider shall submit the "Certification Regarding Lobbying" to the Alliance.
• Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion – Form sent to the Alliance with signed Services Agreement.
• Declaration of Confidentiality – Form sent to the Alliance regarding authorization procedures for release / access of DHS computer files for the Medi-Cal Program, as required by Alliance contract with the State.
• Referral Consultation Request Form (sample only)
This form is for the use of a Primary Care Provider when referring their linked member for specialty care. Referrals to out-of-service-area providers must be approved by the Alliance by submitting a Treatment Authorization Request Form.
• Instructions for completing the Referral Consultation Request Form