Central California Alliance For Health

 

Form Library

Welcome to the Alliance Form Library. Below are links to provider forms, along with brief descriptions of the intended use for each.


Care Based Incentives (CBI) Forms

2018 CBI Forms

PCPs must submit all Fee-for-Service CBI forms within 21 business days of the date of service.


•  2018 Fee For Service (FFS) Forms


Forms for Preventive Care Incentives

Healthy Breathing for Life


Asthma Action Plans (AAP) are no longer a part of CBI 2018 program, but we encourage providers to continue providing the action plans to your patients. The AAP forms are now located in the Forms Library.


Healthy Moms and Healthy Babies (HMHB)


The Alliance's HMHB program is designed to encourage pregnant women to seek early prenatal and postpartum care. These members can earn up to $50 in gift cards.


Early Prenatal Care - Pregnant members who have a prenatal visit (Early Prenatal Care) within their first 13 weeks of their pregnancy or within 42 days of becoming an Alliance member can receive a gift card. PCPs who submit the form to the Plan within 21 business days from the date of services to indicate members have received an initial prenatal consultation will receive payment through our CBI program. The prenatal visit does not need to be a comprehensive official prenatal exam and can simply be a diagnosis of pregnancy and referral to relevant specialist or PCP for continued prenatal services.


Early Prenatal Care Form

• Fillable Early Prenatal Care Form in English or Spanish or Hmong

Postpartum Care - New moms can also receive a gift card for their postpartum visit (Postpartum Care) if they see their PCP within 21-56 days of the birth of their child. The member will receive this incentive once the PCP has billed the Plan for the encounter and no form is required. The provider to which the member is linked at the time of the visit will receive payment for either 1) performing the visit or 2) the visit being performed by a referral specialist.


Healthy Weight for Life


Initial Referral, 6-Month and 12-Month Follow Up Referrals - PCPs may use the form below or their own form to refer members to the Healthy Weight for Life (HWL) program and report members' Body Mass Indexes (BMI) to the Alliance. This program is for members age 2-18 with a BMI at or above the 85th percentile. PCPs that complete and fax these forms to the Alliance at (877) 793-8504 may be eligible for payment through our CBI program. Forms must be completed by the linked PCP site to receive credit.


Please fax only the completed referral form to the Alliance, not the prescription form. Give the completed prescription form to the patient and keep a copy in the patient's file.


Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - English
Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - Spanish
Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - Hmong



Other Forms

Claims

Comments/Suggestions for the Claims Department – Providers can use this form to send comments or suggestions with the Alliance Claims department.

Corrected Claim Form – Providers can use this form to submit corrected claims. The form must be completed in full and the claim must be attached. To prevent delays in processing, please do not staple the claim to the form.

EDI Trading Partner Agreement – All Transaction Types – This application is used to enroll providers as Trading Partners for various EDI transactions, such as 837 Electronic Claims Submission, 835 Electronic Remittance Advice, and others.

Interested in Electronic Claims Submission? – Providers can use this form to request more information on the electronic claims submission process.

Reimbursement Rates Form – Providers can use this form to request reimbursement rate information from the Alliance.


Finance

Credit Balance Report – Participating Hospital Providers are required to complete and submit this form to the Alliance on a quarterly basis.

Provider Identified Overpayment Form – Providers can use this form to report an overpayment made by the Alliance.

OHC Referral Form – Providers can use this form to report an Alliance members’ other Health Coverage.

EFT/ACH Authorization – Providers can use this form to receive electronic payments via Electronic Fund Transfer/Automated Clearing House.

   – EFT/ACH Authorization Form Instructions – This document
   provides instructions on how to complete the Electronic Fund
   Transfer/Automated Clearing House Authorization Form.


Grievance

• Member Complaint Packets – These files can be printed out and handed to members who are interested in filing a complaint to the Alliance's Grievance Coordinator.
   – Member Complaint Packet in English
   – Member Complaint Packet in Spanish
   – Member Complaint Packet in Hmong

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.


Health Education and Disease Management

The Alliance offers many health education and chronic disease management programs to help members get healthy and stay healthy. These programs can give members tools on living healthy lifestyle and managing chronic conditions. Members participating in these programs are also eligible to win a gift card. Click here to learn more about these programs and to access program referral forms.


Health Services

Advance Directives Form, English or Spanish – These advance directives forms are easy for patients to read and understand.

• Asthma Action Plan (AAP) - PCPs may use the form below or their own form to create an AAP for members age 5-64 with a diagnosis of asthma. The AAP provides instructions and information on how to self-manage asthma daily, including taking medications appropriately and how to recognize and handle worsening asthma.

  •  Fillable AAP in English, Spanish, and Hmong


CPT/Procedure Code Inquiry Form – Providers can use this form to check if a CPT code(s) requires Prior Authorization.

Provider Change Request (PCR) Form - Providers can use this form to make simple changes to an existing Prior Authorization.

Authorization Status Request – Providers can use this form to check the status of an authorization request.

Treatment Authorization Request – Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals, and durable medical equipment requests.

Request for Extension of Stay in Hospital – Providers can use this form for an extension of inpatient hospital stays.

Long Term Care Treatment Authorization Request – Providers can use this form to request authorization for long term care.

Community Based Adult Services (CBAS) Inquiry Form – Providers can use this form to inquire about CBAS services for Alliance members.

Consent for Sterilization or Hysterectomy Sample Form – Providers can use this sample form to obtain consent for sterilization or a hysterectomy. Providers are free to duplicate this form and add their letterhead.

Comprehensive Perinatal Services Program (CPSP) – Per Title 22, Section 51348, all contracted providers must perform a comprehensive risk assessment for all pregnant members that is comparable to the American Congress of Obstetricians and Gynecologists (ACOG) and CPSP standards. Providers can use the forms below during an initial prenatal visit, once each trimester thereafter, and at postpartum visits.
  •  CPSP Integrated Initial Assessments 1, 2 and 3 Trimester
      Assessments and Individualized Care Plan
  •  Fee For Service Billing Codes
  •  CPSP Directory

Medi-Cal Provider-Preventable Conditions Reporting Form – Providers are required to send the completed Department of Health Services (DHCS) 7107 form within five working days of discovery to DHCS, Audits and Investigations Division as instructed on the form. A copy must also be sent to the Alliance Quality Improvement Department via fax (using the PPC Submission Fax Cover Sheet).

• Medication Management Agreement (MMA) - PCPs may use this form to create a Medication Management Agreement for their members. PCPs who complete and fax this form to the Alliance may be eligible for payment through our CBI program
  •  MMA in English, Spanish, or Hmong.

• Physician Orders for Life-Sustaining Treatment (POLST) - This incentive is designed to ensure that conversations on end-of-life planning occur with seriously ill patients, allowing them to choose the treatments they want and helping ensure that their wishes are honored by medical providers. Providers who complete and fax the cover sheet and English version of this form to the Alliance may be eligible for payment through our CBI program.
  •  POLST in English
  •  POLST in Spanish
  •  POLST in Hmong
  •  POLST forms in additional languages

Prescription Drug Prior Authorization Request Form – Providers can use this form to request prior authorization for medications for In-Home Supportive Services (IHSS) members.

Request for Administrative Member Classification – Providers can use this form to request that an Alliance member be made an administrative member.

Staying Healthy Assessment Order Form – Use to order bulk quantities of the SHA forms and patient handouts in English, Spanish, and Hmong.
To print SHA forms and handouts directly, please visit the Staying Healthy Assessment page of the Alliance provider website for PDF versions in English, Spanish, and Hmong. Additional languages may be available from the California Department of Health Care Services SHA website.

Please note: Remember to use the SHA during the Initial Health Assessment (IHA) as well as subsequent well exams. Members who schedule an IHA and see their PCP within three months of enrollment with the Alliance as a Medi-Cal member are eligible for a monthly raffle for a $50.00 gift card. This incentive is intended to raise awareness of the importance of developing a good relationship with the PCP, and to improve compliance rates for timely IHAs.


• Synagis Recommendations and Medical Necessity Form – These annual Synagis memos discuss criteria for Synagis and how to obtain prior authorization. For providers who wish to administer Synagis in their office, the Statement of Medical Necessity form is required to be submitted along with the prior authorization request.
   – Instructions for Santa Cruz County and Monterey County
   – Instructions for Merced County

• Transportation:
Providers can use this form to request Non-Emergency Medical Transportation (NEMT) for Alliance members:
   – Physician Certification Statement of Medical Necessity for NEMT
   – Physician Certification Statement Instructions
Providers can use this form to request Non-Medical Transportation (NMT) for Alliance members:
   – Transportation Services Request Form

Provider Services

Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion – Providers can send this form to the Alliance with their signed Services Agreement.

Certification Regarding Lobbying - Exhibit D(F) Att 1 and 2 – Providers receiving payments under a Services Agreement of $100,000 or more are required to submit the Certification Regarding Lobbying form to the Alliance.

Locum Tenens Notification Form – Providers can use this form to notify the Alliance of all locum tenens before they render services to Alliance members. Locum tenens are providers who temporarily take the place of, or cover, for another provider.

Member Appointment No-Show Notification – Providers can use this form to inform the Alliance Member Services department that an Alliance member did not keep a scheduled appointment

Patient Complaint / Grievance Tracking Log – Providers can use this form to track patient requests for Complaint / Grievance Forms.

Provider Applications – If you are interested in becoming an Alliance provider, visit the Joining our Network page.

Provider Dispute Form – Providers can use this form to file a dispute with the Alliance.

Provider Information Change Form – Providers can use this form to update contact and practice information, including the provider’s address, phone number, contact information, payment address, and tax ID number.

Reimbursement Rates Form – Providers can use this form to request reimbursement rate information from the Alliance.

• Request for Member Reassignment – Providers can use this form when requesting member reassignment. Procedures for reference and member notice letters are also linked below.
   – Request for Member Reassignment Form
   – Request for Member Reassignment Procedure

• Member Notice Letters –
   – English
   – Spanish
   – Hmong




























 

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