Provider Manual

Section 3:
Authorizations/Approvals/Referrals/Benefits

Table of Contents
3. Authorizations/Approvals/Referrals/ Benefits
3.1 Referral Authorization Form (RAF)
3.2 Treatment Authorization Request (TAR)
3.3 Pharmacy Services, TARs and Formulary
3.4 Definitions from Medical Services Agreement
3.5 OB-GYN, Family Planning and Sensitive Services Under the Alliance Plan
3.6 Sub-Contracts: Lab, Vision, Pharmacy, Dental, Mental Health
3.7 Services Not Covered Under Medi-Cal Line of Business: “Carve-Outs”
3.8 Out of Network Plan Referrals
3.9 Transportation (Non-Emergent)
3.10 Authorization of Interpreter Services
3.11 Health Programs
3.12 Health Education Services
Attachment A - Hospital Transportation from PCP Office

3. Authorizations/Approvals/Referrals/Benefits                    top

Note: The most current authorization policies may be found here.

The two types of Authorization Forms used by the Alliance are:

Referral Authorization Forms (RAFs)

Treatment Authorization Forms (TARs)

Authorization of services is required as follows:

Or FAX to (831) 430-5850

3.1 Referral Authorization Forms(RAFs)                                   top

A Referral Authorization Form (RAF) is issued by the Primary Care Physician (PCP) to authorize services for their linked members who are case managed by the PCP. A RAF is not required for Administrative members, or members who have Medicare as their primary source of insurance.

Alliance Medi-Cal, Healthy Families, Healthy Kids, and Alliance Care IHSS members also may need a RAF.

RAFs are required for claims consideration on all elective services. A RAF from a PCP to the specialist can be as general or specific as the PCP desires. For instance, if a PCP wants to give broad authorization and writes on the RAF, “services as needed” this means that the Alliance is authorized to pay any claims associated with that RAF (e.g., lab tests and X-rays ordered by the specialist within the specified dates). If the PCP wishes to be specific in authorizing services to be provided by the specialist, the PCP needs to specify this on the RAF (e.g., “two referral visits only” or “ including testing, one time only”). Specialists request that the medical information on the RAF be as specific as possible.

Care should be taken by the PCP in completing RAFs since what is authorized will determine the scope and duration of services and claims paid for these services.

Referral Authorization Form (RAF) Instructions                    top

Member Information

Fill in the member information as it appears on the case management list or ID card.  Also provide the Member’s current Alliance number.

Referral/Consultant Information

Fill in the complete name (first and last), address and telephone number of the physician/provider you wish the member to see.  This information is available in the Alliance Physician/Provider Directory.  Also, please indicate the physician/provider’s Medi-Cal and Alliance PCP/Provider numbers, if known. 

Referral Information

Check appropriate Referral/Consultant Services (one only).

Primary Care Physician’s Reason for Referral 

Please indicate Diagnosis and ICD9 Code in the space provided.  Please list the actual code number; the written description is not sufficient.  Please indicate procedure, if applicable, and date(s) referral is authorized.

History/Comments

Please indicate this information.

PCP Signature

Only the signature of the PCP or the Mid-Level will be accepted as authorization for a referral.

PCP Information

Complete all information required.  If the referral is made by a Mid-Level, please indicate the PCP’s name.

A RAF form includes 3 copies which must be submitted as follows

  1. White - send to the Alliance.
  2. Canary - PCP keeps for their records.
  3. Pink - send to Referral Specialist.

RAF Number

Each RAF has an unique number.  The RAF must be used only once, for one member and one provider.

 

If a member is referred to an out of network provider, Primary Care Physicians must indicate the reason why an Alliance network provider will not be used. Please be sure to date and sign the RAF.

Mail the RAF to:

Central Coast Alliance for Health
ATTN:  Authorizations
PO Box 660012

Scotts Valley, CA  95067-0012

Or FAX to: (831) 430-5850

Sample RAF Form                                                               top 

 

3.2 Treatment Authorization Requests (TARs)      top
Note: During calendar year 2006 TARs will be used for all lines of business.

A Treatment Authorization Request (TAR) is principally used to ensure that elective procedures, hospital admissions, services and supplies are medically necessary and covered as required by State Law.

Title 22, California Code of Regulations (CCR), Section 5100 3 (e) and (f) state “authorization may be granted only for Medi-Cal benefits that are medically necessary…and may be granted only for the lowest cost item or service covered by the program that meets the patient’s medical need.”

Use of Treatment Authorization Request (TAR) Form  

The procedures for completing TARs can be found in the EDS Medi-Cal Provider manual, and in Section 3 in this manual.  To expedite processing of TARs, providers should include:

Submit TARs to:

Central Coast Alliance for Health
Health Services Department
1600 Green Hills Rd. , Suite 101
Scotts Valley, CA  95066

Or FAX to (831) 430-5850

Retroactive TARs                                                                                top

Retroactive TAR Submissions

1. TARs should be submitted prior to provision of a service unless it is emergent or will result in an unnecessary extension of a hospital stay.
2. If a TAR is submitted after a service has been provided or initiated to an Alliance eligible member, it must be received by the Alliance within 30 calendar days of initiation of the services or the request will be denied for non-timely submission.
3. If a TAR is submitted for a member who has obtained retroactive eligibility, it must be received by the Alliance within 60 calendar days of the member obtaining Medi-Cal eligibility or it will be denied for non-timely submission.

The following are conditions whereby a TAR may be submitted for retroactive consideration:

TAR Review

Only licensed medical professionals employed by the Alliance make TAR decisions.  The Alliance has Service Authorization Coordinators who review TARs for completeness and can help you with any aspect of the process, including answering questions regarding the status of TARs (831) 430-5506.

TAR Status Table                                                                                top

Approved as Requested

You may provide service as requested. Please include the RAF# and TAR# on your claim.
Approved as Modified

Most Common Reasons for Approved as Modified TAR decisions 1. Fewer visits are authorized than were requested on the TAR.
2. The number of in-patient days requested on the TAR is not within the length of stay guidelines for the requested procedure.
3. The dates of service requested on the TAR do not match the dates that the member is Alliance eligible.

Deferred

Most Common Reasons for Deferred TAR

  1. TAR incompletely filled out.  TAR lacks:

      a. Procedure (CPT) and/or diagnosis codes (ICD-9)  
      b. Narrative information as to procedure and/or codes that are being requested.

  2. Insufficient medical information written on, or attached to the TAR to make the medical decision.
  3. Patient is not an Alliance member.
  4. Case is open to CCS for the particular medical diagnosis and/or the service being requested.  See CCS Procedures
  5. Services being requested are for dental services or mental health, which are Medi-Cal services that are authorized by other agencies.
  6. Necessary equipment pricing catalog pages not submitted
Denied

A denial letter will be attached to the TAR giving an explanation for the denial.  Appeal rights will also be included with the TAR.  If you need clarification on why your TAR was denied, please call the Alliance’s Authorization Coordinator at (831) 430-5506.

Benefits vary across lines of business.  Some authorization requests for Healthy Families members and enrollees in other lines of licensed business may be denied as plan exclusions.


Pre-Approved TARs                                                            top

Below is the list of procedures for adult patients, grouped by specialties, for which TARs will be pre-approved.
Clarifications regarding the list:

  1. General criteria for eligible procedures:
  2. Available to Alliance-contracted specialists in the specific areas of practice (eligible procedures do not “cross-over” to other disciplines).
  3. TAR will still be required for payment, but may be submitted after the decision and the performance of the service.
  4. Length of stays specified (parentheses after procedure).  If a longer stay anticipated, please submit the TAR prior to the procedure and include the number of in-patient days being requested.  Unanticipated complications may occur, which will be reviewed concurrently and authorized based upon clinical reasonableness.  Only an Alliance Medical Director may issue a denial.
Listing of Eligible Procedures by Specialty Length of Stay
Cardiology  
PCTA 2d
Diagnostic cath including coronary angiography OP
Cardiovascular Surgery  

AV shunt placement and revisions

OP
Dermatology  
Lesion excision and Bx* OP

ENT

 
T&A ≥ 5 years old OP
Hematology/Oncology  
Bone marrow aspiration/biopsy OP
Neurology  
MRI of craniospinal axis* OP
Ophthalmology  
Cataract ± IOL.  Documentation of V.A. to accompany TAR OP
Orthopedics  
MRI of spine, knee, hip, shoulder OP

* Already on pre-auth protocol                                                        top

Notes:

  1. Psychiatric and dental services are “carved out” i.e., not covered in the Medi-Cal line of business. Mental Health services, on a limited basis, are covered for Healthy Families, Healthy Kids, and Alliance Care IHSS plan beneficiaries.  Healthy Families and Alliance Care IHSS plan services are contracted to Managed Health Network.  Healthy Kids Plan (Santa Cruz County only) mental health services are administered by Santa Cruz County Mental Health.  Dental Services for  the Healthy Kids plan is contracted to Delta Dental.
  2. Members under 21 years old requiring procedures will be carefully screened to determine whether they have a CCS qualifying condition, in which case the service is carved out of the Alliance.  For this reason very few procedures on the above list apply to this age group.  This applies to Medi-Cal, Healthy Families, Healthy Kids, and Alliance Care IHSS Members.

Please refer to Section 4, Attachment E of this Provider Manual for the full listing of procedures that do not require a TAR.

Acupunture and Chiropractic Treatment

Medi-Cal Members:

The Medi-Cal program allows for two (2) Medi-Service visits per member per month that do not require a RAF or TAR. This applies to acupuncture and chiropractic treatments. The member is entitled to either two (2) acupuncture or two (2) chiropractic treatments per month, or a combination of one (1) of each. These services are limited to two (2) visits. Any requests received for more services in excess of two (2) per month will be denied as a non-covered benefit.

Commercial Lines of Business:

1. Alliance IHSS Health Plan:

Eligible members require a referral and a pre-authorization for these services. The cost to the member is $10 per visit and the number of visits is limited to 20 per calendar year.

2. Healthy Kids Program:

Eligible members require a referral and a pre-authorization for these services. The cost to the member is $5 per visit and the number of visits is limited to 20 per calendar year.

3. Healthy Families Program:

Eligible members require a referral and pre-authorization of these services. The cost to the member is $5 per visit and the number of visits is limited to 20 per calendar year.

Any requests for more than 20 visits in a calendar year will be denied as not a covered benefit under these programs.

Treatment Authorization Request (TAR)                                        top

The TAR may be submitted to Central Coast Alliance for Health by hand-delivery, fax, or mail.  If the TAR is submitted by FAX, do not submit another copy of this TAR by mail also.  If the projected date for the service is less than ten (10) days in the future, the TAR should be submitted by Fax to avoid delays in the mail.  Urgent TARs will be addressed within one business day, and all TARs will be acted upon within five (5) working days of receipt by the Plan.  All physicians/providers will receive documentation verifying that the TAR has been approved or denied.  If you are uncertain as to whether a procedure requires a TAR, please call (831) 430-5506.

The following checklist is for effective use of a submitted TAR:

Sample TAR Form                                                                           top

 

3.3 Pharmacy Services, TARs and Formulary                top

The Alliance has its own formulary, developed with input from local providers, which is different than the State formulary.  Please refer to the Alliance formulary to find out if a particular medication is listed.  If a patient requires a non-formulary medication, a TAR may be submitted by FAX, (831) 430-5851, to the Alliance office or by mailing the TAR to:

Central Coast Alliance for Health
Health Services Department  - Pharmacy
PO Box 660012
Scotts Valley, CA  95067-0012

The Alliance Formulary is reviewed and updated annually.

Pharmacy TARs

A TAR is required when a prescription is for a drug that:

1. Is not on the Alliance formulary.
2. Exceeds the limit of days/qty allowed per Alliance formulary.

Does this prescription require a TAR?

Yes:
Please submit a TAR to the Alliance
Fax your TAR to: (831) 430-5851

No: Thank you. You can fill this Member’s prescription.

• The prescribing physician or filling pharmacist fills out a TAR for a prescription.
• The TAR can be faxed to the Alliance directly from the doctor’s office or to the pharmacy where member will fill prescription. After which the pharmacy must fax it to the Alliance for review.
• The Alliance will issue the pharmacy a Pre-Authorization number. You will need this number to process prescriptions that require a TAR.

If you need to speak to Alliance pharmacy personnel please contact:

Alliance Pharmacist - (831) 430-5553

Pharmacy Technicians - (831) 430-5500, ext. 5577


3.4 Definitions from Medical Services Agreement          top

The following definitions for Limited Services and Self-Referral Services are from your Medical Services Agreement:

1.19 LIMITED SERVICES shall mean the following services with respect to Medi-Cal Members:  optometry, chiropractor, acupuncture, podiatry, faith healer, physical therapy, occupational therapy, speech therapy and audiology.  Exhibit 3 of your Alliance Health Care Services Agreement describes Limited Services with respect to Other Members.

1.40 SELF-REFERRAL SERVICES refers to Services in addition to Emergency Services that Members are allowed to access without an Authorization, as set forth in the Membership Contracts.  For Medi-Cal Members, Self-Referral Services include optometry, chiropractic, acupuncture, podiatry, prayer, spiritual healing and sensitive services.  Exhibit 3 of your Alliance Health Care Services Agreement describes Self-Referral Services with respect to Other Members.  Self-Referral Services are subject to utilization controls as specified under the Medi-Cal program.

Authorization Process for Limited/Self-Referral Services       top

  1. Call Automated Eligibility line (24 hours/7 days a week) or Alliance Eligibility clerk (8am–5pm, M-F).  See numbers below.
  2. If member is not eligible ask member to call their Medi-Cal eligibility worker or the Healthy Families Program.  If the member is a Healthy Kids member, have them contact the Alliance.  If the member is an Alliance Care IHSS member, have them contact the Monterey Public Authority.
  3. Eligible Alliance Medi-Cal members are allowed a maximum of 2 Limited Allied Provider visits per month without requiring prior authorization.  If a Medi-Cal member will exceed the visit limit, a RAF must be obtained from the member’s PCP and a TAR must be submitted to the Alliance by the Allied Provider.
  4. Eligible Alliance Healthy Families members are allowed a maximum of 20 Chiropractic and 20 Acupuncture visits per benefit year (July 1 – June 30).  No RAF or TAR is required for Healthy Families members.  No additional visits are allowed for Healthy Families members, even with a request for authorization. 
  5. Eligible Alliance Healthy Kids and Alliance Care IHSS members are allowed a maximum of 20 Chiropractic and 20 Acupuncture visits per benefit year (July 1- June 30).  A RAF and TAR is required for Healthy Kids and Alliance Care IHSS members for all chiropractic and acupuncture visits.
  6. Two visits a month service for Medi-Cal members applies only to the following:

Alliance Automated Eligibility Line - 24 hrs, 7days
(831) 430-5501 or (800) 700-3874, ext. 5501

Alliance Member Eligibility Clerks - 8am–5pm M–F
(831)430-5502

3.5 OB-GYN, Family Planning and Sensitive Services under the Alliance Plan

Under Alliance plans, routine OB/GYN services, Family Planning and Sensitive Services are self-referral services and do not require a PCP RAF.

Members are allowed freedom of choice of OB-GYN, Family Planning and Sensitive Services and may receive such services from any properly licensed provider, including those out-of-plan, without prior authorization.

Family Planning and Sensitive Services                                        top

Family Planning Services include birth control and pregnancy testing and counseling.  

Sensitive Services include pregnancy testing and counseling, birth control, AIDS/HIV testing, sexually transmitted disease testing and treatment, and termination of pregnancy.

Family Planning services and Sensitive Services are listed below:

* Pap smear is included as a family planning service if performed according to the United States Preventive Services Task Force Guidelines which specifies cervical cancer screening every 1-3 years based on the presence of risk factors (early onset of sexual intercourse, multiple sexual partners); however, PAP smear annual frequency may be reduced if 3 or more annual smears are normal.
** Based on HCFA’s medicaid policies, STD diagnosis and treatment and HIV testing and counseling, provided during a family planning encounter, are considered part of family planning services. 

Please Note:  Infertility services are NOT covered under Family Planning and are excluded along all lines of business.

3.6 Sub-Contracts:  Lab, Vision, Pharmacy, Dental, Mental Health   

3.6.1 Laboratory Services                                                  top

The Alliance contracts with Stanford Clinical Laboratory for laboratory services.  Alliance members who live out of our service area may receive services at any Medi-Cal certified lab. Please see Section 4.0 – Claims of this manual to determine where to send all claims for lab services provided to Alliance members.

3.6.2 Vision Services                                                                 top

The Alliance sub-contracts with Vision Services Plan (VSP) to provide vision services to Medi-Cal and to Healthy Kids members.  Members must go to a VSP Medi-Cal participating provider for refraction services, or eye glasses.  (Healthy Families Members access their vision services out of the plan and vision services are not a covered benefit for Alliance Care IHSS members).

3.6.3 Pharmacy Services                                              top

The Alliance has subcontracted with Express Scripts Inc. to provide all pharmacy services to Medi-Cal, Healthy Families, and Healthy Kids, and Alliance Care IHSS members.  Members must go to an ESI participating pharmacy for prescriptions.  The Alliance’s formulary is available online at ePocrates.com.

3.6.4 Dental ServicesHealthy Kids Members Only   

The Alliance contracts with Delta Dental to provide dental services to Alliance Healthy Kids Members.  Healthy Kids Members may access dental providers by calling (877) 580-1042. 

3.6.5 Mental Health Services                                                     top

The Alliance sub-contracts with Managed Health Network (MHN) to provide mental health services to Alliance Healthy Families and Alliance Care IHSS Members.  Healthy Families and Alliance Care IHSS Members may access mental health providers by calling MHN at (800) 327-0449.

The Alliance sub-contracts with Santa Cruz County Mental Health to provide mental health services to Alliance Healthy Kids Members.  Healthy Kids Members may access mental health providers by calling (800) 952-2335. 

Mental Health Services for Medi-Cal Members is carved out of the Alliance Contract, see Section 3.7 of this Manual.

3.7 Services Not Covered Under the Medi-Cal Line of Business: 
         “Carve-Outs”
      top

The following services are covered under the State Medi-Cal program - billable to EDS rather than The Alliance.

Coordination Regarding Non-Covered Services                          top

(a) Provider shall identify and refer Members with CCS eligible medical conditions to the local CCS (California Children Services) Program.  The local CCS program will authorize such services.  The Alliance-CCS Liaison Case Manager can guide you through the CCS referral process.  Please call the Alliance at (831) 430-5562 to speak with the Case Manager.

CCS in:

Phone Number

FAX Number

Monterey County

831-755-5500

831-783-0720

Santa Cruz County

831-763-8900

831-763-8910

(b) Provider shall provide assistance to Medi-Cal Members needing specialty mental health services by referring such Medi-Cal Members to the local Medi-Cal mental health plan.  If the Medi-Cal mental health plan is not operational or if the Medi-Cal Member’s diagnosis is not covered by the local Medi-Cal mental health plan, Provider shall refer such Member to other appropriate community resources.  Provider shall coordinate services with the Medi-Cal Member’s mental health provider, as appropriate.

(c) When applicable, Provider shall assist members in obtaining services that are not Covered Services, including but not limited to, referring Members to public programs for which the Member may be eligible.

3.8 Out of Network Plan Referrals                                   top

Primary Care Physicians/Providers (PCPs) may refer Alliance Medi-Cal members to any local specialist who is willing to accept the referral and Medi-Cal reimbursement, and who has a Medi-Cal provider number, even if they are not contracted with the Alliance.  Please call the specialist before making a referral.

Referral of Alliance Members

Only the member’s current PCP may issue a Referral Authorization Form (RAF).  To identify a member’s PCP call Alliance Eligibility Verification Clerks at (831) 430-5502 from 8:00 am to 5:00 pm, Monday through Friday, or call the 24 hour eligibility verification line (831) 430-5501 or (800) 700-3874, (you must have the member’s Social Security Number or Alliance ID Number).

When a member’s medical condition requires services not available through network specialists, the PCP may authorize the services of Medi-Cal providers outside of the Alliance network.

3.9 Transportation (Non-Emergent)                         top

Policy: Non-emergency medical transportation requires prior authorization for all lines of business. Refer to attached criteria for both Medi-Cal and Healthy Families for covered and excluded services.  Transportation services will only be provided for eligible members physically unable to access public or private forms of conveyance to access medically necessary services.

Procedure:

Non-emergency Transportation Benefit Coverage
Med-Cal Line of Business Only

Policy: Pursuant to Section 2.56 of the Alliance Contract with DHS, non-emergency medical transportation services are reimbursed to allow members physically unable to access forms of public and/or private conveyance.  Transportation is authorized only for accessing medical appointments and other medically necessary covered services as defined by the Contract. 

Title 22, Section 51323:  “Ambulance, litter van and wheelchair van medical transportation services are covered when the beneficiary's medical and physical condition is such that transport by ordinary means of public or private conveyance is medically contraindicated, and transportation is required for the purpose of obtaining needed medical care.”

Non-emergency Medical Transportation Matrix Covered/Non-Covered Rides

Covered Transportation

Non-Covered Transportation

Physician visits

Certification for ADA, Social Security, Housing Authority

Specialist visits including podiatrists

Senior Centers

Outpatient treatment (radiology, outpatient surgery, chemotherapy, etc)

***Services for any CCS condition including Medical Therapy Unit—refer to CCS criteria

Pharmacy—MD prescribed medication pick-ups

Child care centers

Outpatient County reimbursed mental health services

  • psychiatrist
  • icensed psychologist
  • MFT
  • LCSW

Schools or educational facilities including, but not limited to:

  • elementary
  • special education, child and adult
  • college courses
  • vocational rehab
  • gym activities
  • REAP program
  • Duncan Holbert
  • AB Ingram
  • Stroke Center
  • Salinas Adult School

DME Services

Gym and Swim Centers (Simkin, Hartnel, Kerin, etc,)

Allied Health Services*
  • OT**
  • PT**
  • Speech**
  • Audiology
  • Chiropractic
  • Acupuncture
  • Vision Services

Social activities and non-medically related activities of daily living 

  • shopping
  • post office
  • video rentals
  • visiting
  • religious activities
  • visiting family/friends
  • malls and shopping centers

Dental

Methadone Clinic
12 Step Programs
Substance Abuse Rehab Programs and Facilities

Hospital discharge by gurney

Homeless Persons Health Project

 

Shelters and Food Banks

 

Adult Day Health Care

 

Weight Watchers

 

Support Groups

* Check age for possible CCS conditions
** Screen for excluded LEA services
*** Refer to CCS NL: 16-0801 which outlines CCS’ transportation responsibilities

Non-emergency Transportation Benefit Coverage
Healthy Families and Other Lines of Licensed Business Only
  top

Policy: Non-emergency medical transportation is covered on a limited basis under the Healthy Families Plan to allow members physically unable to access forms of public and/or private conveyance.Transportation is authorized only for accessing medical appointments and other medically necessary covered services as defined by the Evidence of Coverage.   There is no co-payment.  Prior authorization is required in all instances.

Non-emergency Medical Transportation Matrix
Covered/Non-Covered Rides

Covered Transportation

Non-Covered Transportation

Hospital to hospital or facility if prior approved by the plan.

Certification for ADA, Social Security, Housing Authority

Hospital or facility to home if prior authorized by the plan.

Stroke or Senior Centers

Transportation is covered outside of the service region to see a specialist under the following conditions with prior authorization by the health plan:

  • There are no appropriate specialists within the plan service available to provide medically necessary treatment
  • There is no other access to transportation through friends or family and the member is physically unable to use public forms of transportation

***Services for any CCS condition including Medical Therapy Unit—refer to CCS criteria

 

Child care centers

 

Schools including, but not limited to:

  • elementary
  • college courses
  • vocational rehab 
  • gym activities
  • REAP program 
  • Duncan Holbert
  • AB Ingram 
  • special education, child and adult
 

Gym and Swim Centers (Simkin, Hartnel, Kerin, etc,)

 

Social activities and non-medically related activities of daily living

  • shopping
  • post office
  • video rentals
  • religious activities
  • visiting family/friends
  • malls and shopping centers
 

Methadone Clinic
12 Step Programs
Substance Abuse
Rehab Programs and Facilities

 

Homeless Persons Health Project

 

Shelters and Food Banks

 

Adult Day Health Care

 

Weight Watchers

 

Support Groups

 

Pharmacy 

 

Mental Health Appointments—unless the provider is out of the service region and there is no other form of transportation available.

 

School based services

 

Allied health services

* check age for possible CCS conditions 
*** refer to CCS NL: 16-0801 which outlines CCS’ transportation responsibilities

3.10 Authorization of Interpreter Services                                               top

Policy: All Limited English Proficiency (LEP) members are entitled to interpreter services when accessing medically necessary health care services. Interpreter services are accessed by providers through the use of Language Line Services.  By exception, face-to-face interpreters are authorized using the criteria below.  

Authorization Procedure:

1. A provider initiates requests for face-to-face interpreter services by calling the Transportation and Language Coordinator (TLC) at (831) 430-5625.

2. Provider must indicate the type of appointment, the language required, the name, address, and phone number of the provider who will be seeing the member, and the date and time of the medical appointment. (The provider may request a specific interpreter for continuity of care; the TLC and Interpreter Agency will make every effort to schedule the interpreter requested, if available.)

3. The TLC will verify member eligibility and ensure that the request is for a covered service. If the member is ineligible or the request is not for a covered service, the TLC will verbally inform the provider.

4. If the request for a face-to-face interpreter falls into the criteria for use of the language line, the TLC will verbally inform the provider. Should the provider dispute use of the language line, the call will be directed to either the Health Services Director or Medical Director.

5. The TLC will screen all requests to determine if the request is for a CCS, Local Education Authority (LEA) or Medi-Cal Mental Health service. If the service is CCS, LEA or Mental Health, the provider will be referred to the appropriate agency. If there is doubt as to which agency should assume responsibility the Health Services Director or Medical Director will be consulted.

6. Upon approval of a face-to-face interpreter, the TLC will verify the time and place of the appointment, and contact the Interpreter Agency by phone, fax or e-mail. The TLC will provide Interpreter Agency with the following information:

7. The TLC will issue the Interpreter Agency a unique authorization number. The Interpreter Agency must submit the authorization number with the claim or invoice to ensure payment.

Language Services                                                                             top

Telephone Interpreter Service

Face-to-Face Interpreters
(Prior authorization required)

All routine office visits

End of life issues

Pharmacy

Sign language for the deaf (includes routine appointments and services listed to the left as necessary)

All allied services

Sexual assault/abuse issues

All clinic visits

Complex courses of therapy or procedures
(chemo, transplants)

Free standing radiology, mammography, lab services

Others by exception

Health education programs

 
Note: Federal law requires hospitals to provide their own interpreters.
Note: CCS is responsible for provision of culturally and linguistically appropriate interpreter services.
Note: County Mental Health Departments are contractually obligated to provide linguistic services when providing mental health services.

3.11 Health Programs                                                                top

The Alliance has many programs to help members stay healthy. For more information, contact the Health Programs Manager at 831-430-5569. Members may call the Member Health Education Line at 1-800-700-3874 x5580.

Asthma Education – Promotes self-management, appropriate use of medication, and regular medical care.

Breastfeeding Support – Helps new moms succeed at breastfeeding. The Alliance covers lactation counseling for mothers who need extra support and breast pumps for moms returning to work or school.**

Diabetes Education – Promotes self-management and regular medical care, including blood tests for HbA1c and lipids, annual eye exams and foot exams.**

Reducing Emergency Room Use – Teaches members how to avoid the emergency room when possible. Members learn how to manage chronic illness to stay healthier, and parents learn what to do for sick children.

Immunization Outreach – Promotes that all children are fully immunized by age two.

Nutrition and Weight – Teaches members how to eat better to stay healthy. Refers members to free or low-cost exercise and weight loss programs in their area. Provides free pedometers or exercise videos on request.

The Alliance covers brief medical nutrition therapy when medically necessary. For longer term support for severely obese members, the Alliance offers a limited number of scholarships to Weight Watchers; the PCP must complete a brief application form to sponsor the member.

Perinatal Health – Encourages pregnant women to get early and regular prenatal care and a timely postpartum visit. Members earn a $20 gift card for completing their postpartum visit 21 to 56 days after the birth.

Smoking Cessation – Helps members quit smoking with referrals to free phone counseling or scholarships to local classes. The Alliance covers smoking cessation aids (nicotine gum and patches or Zyban) with a doctor’s prescription and certificate from a cessation program.

Teen Tune-Up! – Promotes annual well-care for members ages 12-21. Teens can get a free gift card for going to their annual well visit. They also get a chance to win a mountain bike and helmet.

Women’s Health – Encourages routine screening for cervical and breast cancer.

Disability Services

For more information, contact the Health Programs Manager at 831-430-5569.

Children with Special Health Care Needs – Our Children’s Case Manager helps parents get the care and services their children need.

People with Disabilities – Our Medical Social Workers act as disabilities liaisons. They help members get equipment and coordinate services.

Long Term Care – Our Long Term Care Case Managers help with placements for members who need skilled nursing care. They make sure members get the best care possible.

Wheelchair Clinic – Teaches members how to maintain their wheelchairs. Experts consult and repair wheelchairs at no cost to the user.

3.12 Health Education Services                                      top

The Alliance offers a range of health education services for providers and members. Specific programs are outlined below. Health education is also integrated with Alliance Quality Improvement initiatives and Health Programs.
For more information:

Health Education Benefits

To improve the health of our members, the Alliance pays for several clinical health education services. These services are covered for all Medi-Cal, Healthy Families, Healthy Kids and Alliance Care IHSS members. A Referral Authorization Request (RAF) is not required except for Medical Nutrition Therapy. For asthma, diabetes, or lactation education, members may be referred by their primary care provider (PCP), other physician, Alliance Case Management, or self-referral.

The health education benefits are summarized below. For more details on each benefit and a list of approved education providers, visit the Alliance website or call the Senior Health Educator at 831-430-5570.

Patient Education Materials

Alliance Health Education staff assist providers with patient education materials in several ways. Per our Medi-Cal and Healthy Families contracts, we specialize in materials that that are suitable for low-literacy readers, culturally appropriate for our membership, and available in both English and Spanish. For assistance, please contact the Senior Health Educator at 831-430-5570.

Member Health Education Line: 1 (800) 700-3874 x5580

Please refer your Alliance patients to our Member Health Education Line for help accessing health education services. The line is answered by our Health Programs Coordinators who are bilingual in English and Spanish. They can help members with:

Outreach to Members and Providers

In addition to the direct member outreach described in Section 3.11 – Health Programs, health education outreach includes:

Attachment A 
Hospital Transportation from PCP Office                              top

On occasion members require admission to acute care facilities directly from the Primary Care Provider’s (PCP) office. The Alliance will reimburse the costs of transportation to the hospital.  This policy does not include transportation to other care sites (pharmacies, outpatient therapy, etc.)

Policy:

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