The Alliance medical services staff manages authorizations for members assigned to directly contracted providers.

Authorization requests for members assigned to delegated medical groups are managed by the medical groups. Please refer to the coverage policies and utilization criteria of the respective medical groups.

For information regarding In-Office Injectables, please click here.

Providers can locate a member’s assigned medical group by referring to the back of the member’s Alliance member ID card, or logging into the Alliance Provider Portal and search for the member.

Providers can also call us for assistance:

Alliance Provider Services Department
Monday – Friday, 7:30 am – 5 pm
Phone Number: 1.510.747.4510

Delegated Medical Group contact information:

Children First Medical Group
Phone Number: 1.510.429.3489
Fax: 1.510.450.5868
www.childrenfirstmedicalgroup.org

Community Health Center Network
Phone Number: 1.510.297.0220
Fax: 1.510.297.0222
www.chcnetwork.org

For a complete list of services that require authorizations, please view the Alliance Referral and Prior Authorization (PA) Grid for Medical Benefits (for directly contracted providers only).

Authorization Submission

The Alliance Prior Authorization (PA) Request Form is used for all services requiring prior authorization from the Alliance. The Alliance Provider Services Department supplies all of the Alliance’s contracted providers with the PA.

Alliance Prior Authorization Form | Instructions

If you would like to submit a PA request for breast pumps, please use the Breast Pump Request Form.

Denials and Appeals

所有拒絕承保的利用率審查決定均由醫療總監聯盟團隊做出。 在某些情況下,服務請求的外部審查可能由具有適當臨床專業知識的合格執業醫生進行。

拒絕通知通過傳真發送給請求提供程式,並郵寄給成員。 拒絕通知將包括拒絕的理由、對作出拒絕決定的優惠規定和/或臨床指南的提及,以及如何獲取參考副本的說明。

我們的政策是讓適當的從業者審閱者與請求供應商討論任何拒絕決定。 拒絕通知將包括聯盟?部門對等電話線路資訊。

提供者可以通過聯繫以下人員提交申訴:

聯盟提供者服務部門
週一和週五,上午 7:30 至下午 5:00
電話號碼: 1.510.747.4510
電子郵件: providerservices@alamedaalliance.org

欲瞭解更多資訊,請查看申訴和上訴。

Inpatient Review

The Alliance UM Department has a transition of care (TOC) team made up of inpatient nurses who are assigned to follow members admitted for inpatient care, at specific acute care facilities. The Alliance TOC team works to promote collaboration with the facility’s review staff and support the member across the continuum of care. Our TOC team applies MCG® Care Guidelines to assess the care and services provided in inpatient settings and our member’s response to the care. The TOC team works with the facility’s staff to coordinate the member’s discharge needs.

All elective facility admissions require a Prior Authorization (PA) Request Form.

Please be sure to include all clinical documentation to help ensure a timely turnaround. The facility is responsible for ensuring authorization and admission.