1.0 Introduction
1.1 How to Use the Plan Provider Manual
1.2 What is Central Coast Alliance for Health
1.3 State Medi-Cal Programs, EDS, DMHC and The Alliance
1.4 Application, Credentialing and Contracting
1.5 Contractual Requirements for Credentialing and Regulatory Compliance
1.6 Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion
Attachment A - Contact List
2.0 Alliance
Membership
2.1 Eligibility by Plan
2.2 The Member Services Department
2.3 Primary Care Provider (PCP) Assignment
2.4 Identification of Members
2.5 Medi-Cal Members with a Share of Cost (SOC)
2.6 Member Identification Cards
2.7 Medi-Cal Aid Codes
2.8 How to Verify Eligibility (by Provider Type)
2.9 Cultural and Linguistic Services
2.10 Interpreter Services
3.0 Authorizations
/ Approvals / Referrals / Benefits
3.1 General RAF/TAR Requirements
3.2 Referral Authorization Form (RAF)
3.3 Treatment Authorization Request (TAR)
3.4 Pharmacy Services, TARs and Formulary
3.5 Definitions from Medical Services Agreement
3.6 OB-GYN, Family Planning and Sensitive Services Under the Alliance Plan
3.7 Sub-Contracts: Lab, Vision, Pharmacy, Dental, Mental Health
3.8 Services
Not Covered Under Medi-Cal Line of Business: “Carve-Outs”
3.9 Out of Network / Plan Referrals
3.10 Transportation (Non-Emergent)
3.11 Authorization of Interpreter Services
3.12 Health Programs
3.13 Health Education Services
Attachment A - Hospital Transportation from PCP Office
4.0 Claims
4.1 About
the Claims Department
4.2 Claim Forms by Provider Type
4.3 Frequently Asked Questions
4.4 Medicare / Medi-Cal Crossover Claims
4.5 Commercial Insurance / The Alliance
4.6 Healthy Families Claims
4.7 Healthy Kids Claims
4.8 Alliance Care IHSS Claims
4.9 Laboratory / Pathology Payable Codes
4.10 Sensitive Services Billing
4.11 TAR / Non-Benefit
Attachment A - The CMS-1500 and UB-04 Claim Forms
Attachment B - Modifiers
Attachment C - Delay Reason Codes
Attachment D - CCAH Prior Authorization Exception List Procedures not
requiring prior authorization for members Aged 21 or older
Attachment E - Electronic Claims Submission
Attachment F - CHDP
5.0 Case
Management / Reporting Responsibilities
5.1
Case Management Definition, Objectives, Responsibilities (Including
Health Assessment and Screening)
5.2 Plan Utilization Management Program
5.3 Quality Management Plan / Quality Assurance and Improvement
5.4 Coordination of Care Policies
5.5 Long Term Care, Discharge Planning
5.6 Emergency Services Notification
5.7 Records and Reporting Responsibilities
5.8 Member Delete Procedure
5.9 Appointment No-Show Follow-Up Procedures
5.10 Administrative Member Request
Attachment A - Adult Preventive Care and Childhood Preventive Care
Attachment B - Quality Management Plan / Quality Assurance and Improvement
6.0 Dispute
Resolution, and the Alliance Grievance Process
6.1 Overview
6.2 Provider Dispute Resolution
6.3 Member Complaints
6.4 Member Complaints and the Alliance Grievance Process
6.5 Member Rights in the Alliance Grievance Process
7.0 Forms