A. Submitting Claims to the Alliance

Providers should review the Alliance member ID card for the claims billing address.

Providers are encouraged to submit claims electronically. However, if sending claims by US Postal Service (USPS), claims for all Alliance members should be submitted for processing as follows:

Professional Claims

Alliance members assigned to an Alliance primary care provider (PCP):

Alameda Alliance for Health
P.O. Box 2460
Alameda, CA 94501-0460

Alliance members assigned to a Children’s First Medical Group (CFMG) PCP:

Children’s First Medical Group
P.O. Box 99680
Emeryville, CA 94662-9680

Alliance members assigned to a Community Health Center Network (CHCN) PCP:

Community Health Center Network
101 Callan Ave, Suite 300
San Leandro, CA 94577

Hospital/Facility Claims

Hospital/facility claims for all Alliance members:

Alameda Alliance for Health
P.O. Box 2460
Alameda, CA 94501-0460

Behavioral Health Care Claims

Behavioral health care professional claims for mild to moderate services for Alliance Medi-Cal members:

Beacon Health Options
P.O. Box 1862
Hicksville, NY 11802-1862

Behavioral health care professional claims for specialty mental health services for Alliance Medi-Cal members:

Alameda County Behavioral Health Care Services
Claims Processing Department
P.O. Box 738
San Leandro, CA 94577

Behavioral health care facility claims for Alliance Medi-Cal members:

Alameda County Behavioral Health Care Services
Claims Processing Department
P.O Box 738
San Leandro, CA 94577

Behavioral health care claims for Alliance Group Care members:

Beacon Health Options
P.O. Box 1862
Hicksville, NY 11802-1862

Vision Care Claims

Vision care claims for Alliance Medi-Cal members:

March Vision Care
6701 Center Drive West Suite 790
Los Angeles, CA 90045

Vision care claims for Alliance Group Care members:

Alameda County Public Authority for IHSS
Phone Number: 1.510.577.3552

Dental Claims

Dental claims for Alliance Medi-Cal members:

Denti-Cal
P.O. Box 15610
Sacramento, CA 95852-0610

Dental claims for Alliance Group Care members:

Alameda County Public Authority for IHSS
Phone Number: 1.510.577.3552

Electronic Claims

Providers interested in submitting claims electronically via Electronic Data Interchange (EDI) should call:

Please Note: Claims that require attachments, invoices, etc. may not be sent electronically. They must be submitted on the appropriate paper claim form with the attachments.

B. Reaching the Alliance for Claims

Alliance contracted providers can view claims and status by logging into the Alliance Provider Portal.

For information on how to obtain an Alliance Provider Portal account, additional claim submission requirements, or more complex claim inquiries, please contact your Alliance Provider Representative or call:

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

When requesting the status of a claim, you must identify yourself and provide the following information:

• Alliance member date of birth
• Alliance member ID number
• Alliance member name
• Billed charges
• Claim date of service
• Provider name
• Provider tax ID number

If a caller requests the status of a claim and cannot provide all information listed above, the claim status will not be released.

C. 索賠收據驗證

可通過聯盟提供商門戶或致電:在線獲得索賠收據的驗證:

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

聯盟將在15 個工作日內確認收到紙質索賠。 以電子方式收到的索賠將在兩(2) 個工作日內確認。

D. 索賠提交要求

索賠提交時限

• 參與(簽約)供應商必須在服務后180 個日曆日內提交乾淨的索賠,如果存在其他保險,則從福利說明 (EOB) 起提交郵寄日期。
• 非參與(非合同)提供商必須在服務后365 個日曆日內提交乾淨的索賠,如果存在其他保險,則從 EOB 發佈日期提交乾淨的索賠。
• 已更正的索賠必須在上次訴訟的180 個日曆日內正確提交,以便重新審核付款。 更正後索賠可能誤認為是重複提交索賠,除非明確將其標識為已更正的索賠。

在申報期以外提交索賠

如果索賠是在上述時限之外提交的,則遲交的索賠必須附上適當的檔,也稱為”及時提交證明”。

可接受的及時備案證明,包括

• 聯盟收到了證明索賠的核證郵件收據。
• 如果索賠因 EOB 的不合時宜而被拒絕,則主要付款人提供匯款通知 (RA) 或 EOB 的副本,註明解決日期(付款日期、爭議日期、拒絕或通知)。
• 聯盟電子資料交換 (EDI) 預處理接受或錯誤報告的副本,適用於最初以電子方式提交的索賠。
• 聯盟RA的副本,說明最初拒絕不乾淨的索賠的日期和原因。
• 當供應商遇到超出其控制的特殊情況時,延遲向聯盟提交索賠的原因的文件/說明。

索賠處理時間

聯盟將在收到后45個工作日內處理所有乾淨的索賠。

清潔索賠

乾淨索賠被定義為在最初提交索賠時包含確定付款人責任和及時付款所需的所有必要資訊、附件和補充資訊或檔。

索賠利息

聯盟將根據AB1455和及時付款要求,在收到其乾淨的索賠后45個工作日內,計算並自動向未報銷付款的所有服務提供者支付利息。

誤入歧途索賠

如果向聯盟發送的索賠被錯誤地發送給其委派的合作夥伴之一(即社區健康中心網路 (CHCN)、兒童第一醫療集團 (CFMG)、Kaiser、Beacon 健康選項、3 月願景),聯盟將將索賠轉發給內部相應的委派合作夥伴 自收到索賠之日起十個工作日內。 供應商還將在其 RA 上收到拒絕通知,並指示向委派的實體收費。

索賠編碼

聯盟有責任控制我們的供應商和所有成員的醫療保健成本。 索賠編碼和編輯使我們能夠更有效和普遍地執行公平的報銷規則和準則,旨在防止欺詐和向所有供應商提供公平的報銷。

• 聯盟遵循 Medi-Cal 計費要求和國家正確編碼計劃 (NCCI) 進行編碼,除非另有說明。
• 麻醉服務應通過使用I級CPT5位麻醉程式代碼 (00100-01999) 以及AMA當前程式術語的麻醉指南中定義的修飾符代碼進行報告。
• 聯盟根據需要每年、每季度或每月更新所有系統以獲取新代碼。 新代碼將在 Medi-Cal 宣佈或通過新代碼後的第一個月生效並被聯盟接受。

索賠表要求

聯盟規定了提出付款考慮索賠的要求。 不遵守這些要求可能會影響索賠的償還。

要被接受為有效索賠,提交必須符合以下條件:

• 必須以 CMS 1500、CMS-1450 (UB04) 或 ANSI X12-837-5010 或最新電子格式的標準當前版本提交。
• 必須在所有必填欄位中包含適當的資訊。
• 必須是在服務時符合資格的聯盟成員的索賠。 提供者可以通過聯盟提供商門戶在線確認會員的資格,或撥打以下電話:

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

• 必須包含正確的當前國家標準編碼,包括但不限於 CPT、HCPCS、收入、NDC 和 ICD-10 代碼以及 Medi-Cal 本地代碼(視適用)。
• 不得通過手寫添加到程式代碼和/或費用而改變。
• 必須由呈現提供程式簽名(如果作為紙質聲明提交)。
• 必須用足夠重的深色墨水列印,如果作為紙質索賠提交,則需以電子圖像形式列印。
• 三級 HCPCS(本地代碼)將按照 DHCS 過渡到二級 HCPCS 和 CPT 編碼的計畫進行接受。
• 加州法規要求,為 Medi-Cal 成員提供的絕育服務索賠,包括輸卵管絕育、輸精管切除術和子宮切除術服務,必須附有 PM330 表格,該表格在手術日期前至少30 天由會員簽署。 因此,聯盟不會報銷與絕育服務相關的專業或設施費用,除非主外科醫生提交適當填寫的同意書。 沒有此表格提交的索賠將被拒絕付款。
• 向辦公室注射劑計費的索賠必須包括格式正確的 NDC 代碼和度量單位。 沒有 NDC、度量單位或格式不正確的辦公室可注射代碼將被拒絕。 有關其他詳細資訊,請參閱Medi-Cal 提供者手冊。
• 請參閱下面的書面索賠提交示例。

NDCs and units billed on CMS1500:

NDCs and units billed on CMS1450:

Additional Information

All disposable and incontinence supplies must be billed with the Universal Product Number (UPN) in addition to the HCPCS Level II code. For EDI claims, impacted medical supply products must be billed with HCPCS Level II codes using the ASC X12N 837P 5010 format. Claims billed without the UPN or medical supply claims which are not submitted in the required format will be denied. For additional details, please refer to the Medi-Cal Provider Manual.

See example of paper claim submission below.

Laboratory/Pathology Services

Except for emergency and urgent care services, and those lab services identified as covered under PCP capitation or specifically identified as reimbursed fee-for-service (FFS), laboratory services are carved out to the Alliance’s capitated laboratory provider, Quest Diagnostics. Pathology services, identified as CPT-4 procedure Code range 88300-88399, are payable by the Alliance only when performed in conjunction with emergency or urgent care services, or surgical services performed in an inpatient hospital, outpatient hospital, or free standing surgical facility setting.

A. Definition of Contracted Provider Dispute

A contracted provider dispute is a provider’s written notice to the Alliance challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered) or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum, the following information: provider name, provider ID number, provider contact information, and:

1. If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from the Alliance to a contracted provider, the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;
2. If the contracted provider dispute is not about a claim, a clear explanation of the issue, and the provider’s position on the dispute; and
3. If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, the date of service, the provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.

B. Sending a Contracted Provider Dispute to the Alliance

Contracted provider disputes submitted to the Alliance must include the information listed in Section II.A., above, for each contracted provider dispute.

All contracted provider disputes must be mailed or faxed to:

Alameda Alliance for Health
ATTN: Provider Dispute Resolution (PDR) Unit
P.O. Box 2460
Alameda, CA 94501-4506
Fax: 1.855.891.7173

C. Time Period for Submission of Provider Disputes

Contracted provider disputes must be received by the Alliance within 365 days after the last date of action that led to the dispute, or in the case of inaction, contracted provider disputes must be received within 365 days after the provider’s time for contesting or denying the claim has expired.

Contracted provider disputes that do not include all required information as set forth above in Section II.A. may be returned for completion. An amended contracted provider dispute that includes the missing information must be submitted to the Alliance within 30 working days of a returned contracted provider dispute.

D. Acknowledgment of Contracted Provider Disputes

The Alliance will acknowledge receipt of all contracted provider disputes within 15 working days of the date of receipt.

E. Contact the Alliance Regarding Contracted Provider Disputes

All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to:

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

F. Time Period for Resolution and Written Determination of Contracted Provider Dispute

The Alliance will issue a written determination stating the pertinent facts and explaining the reason(s) for its determination within 45 working days from the date of receipt of the contracted provider dispute or the amended contracted provider dispute.

If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, the Alliance will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) working days of the issuance of the written determination.

A. 非合同提供者糾紛的定義

非合同提供者爭議是非合同供應商向聯盟或其委派集團發出的書面通知,對索賠提出質疑、上訴或請求重新審議(或捆綁的一組基本相似的索賠,個別被否決、調整或質疑或質疑要求償還多付索賠的編號。 每個非合同提供者爭議至少必須包含以下資訊:供應商名稱、供應商 ID 號、供應商聯繫資訊以及:

1. 如果非合同供應商的爭議涉及索賠或要求向供應商多付索賠,則必須提供以下內容:明確識別爭議專案、服務日期和明確解釋提供商認為付款金額、要求提供額外資訊、提出異議、拒絕、要求為多付索賠或其他行為報銷的依據不正確;
2. 如果非合同提供者爭議涉及註冊人或註冊人組、登記者的姓名和識別號,則明確解釋爭議專案,包括服務日期、供應商對爭議的立場,以及登記者的書面授權,使提供者能夠代表該登記者。

B. 向聯盟傳送非合同供應商爭議

提交給聯盟的非合同提供商爭議必須包括第三節中列出的資訊。A. 上文,針對每個非合同提供者糾紛。

所有非合同提供者的爭議必須郵寄或傳真至:

阿拉米達健康聯盟
ATTN:供應商爭議解決(PDR)單元
郵政信箱 2460
阿拉米達, CA 94501-4506
傳真: 1.855.891.7173

C. 提交非合同提供者爭議的時限

非合同提供商爭議必須由聯盟在導致爭議的最後訴訟日期后365 天內收到,或者,如果發生不作為,非合同提供商爭議必須在提供商提出異議或拒絕索賠的時間到期后365 天內收到。

非合同提供者爭議,不包括上述第三節中所述的所有必要資訊。A. 可以返回完成。 已修正的非合同提供者爭議(包括缺失資訊)必須在退回合同提供商爭議后的30 個工作日內提交給聯盟。

D. 確認非合同提供者糾紛

聯盟將在收到之日起15 個工作日內確認收到所有非合同供應商爭議。

E. 就非合同供應商糾紛與聯盟聯繫

有關合同提供者爭議或提交合同供應商爭議的所有查詢必須定向至:

聯盟提供者服務部門
週一至週五,上午 7:30 至下午 5:00
電話號碼: 1.510.747.4510

F. 非合同提供者爭議的解決和書面裁定的時間段

聯盟將在收到非合同提供者糾紛或經修正的非合同提供者爭議之日起45個工作日內發佈書面裁決,說明相關事實並解釋其確定的原因。

如果非合同提供者爭議或經修正的非合同提供者爭議涉及索賠,且全部或部分有利於供應商,聯盟將支付任何確定到期的未償款項,以及所有利息和罰金法律或法規要求,在 五(5)個工作日發出書面決定。

View and download the Provider Dispute Resolution (PDR) form. 

A. Notice of Overpayment of a Claim Form

If it has been determined that a claim has been overpaid, the Alliance will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the date of service(s) and a clear explanation of the basis upon which the Alliance believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.

B. Contested Notice

If the provider contests the Alliance’s notice of overpayment of a claim, the provider must send written notice to the Alliance within 30 working days from the receipt of the notice of overpayment using the Alliance PDR form. The form must state the basis upon which the provider believes that the claim was not overpaid. The Alliance will process the contested notice in accordance with the contracted and non-contracted provider dispute resolution process described in Sections II and III above.

C. Offset to Claim Payments

The Alliance may only offset an uncontested notice of overpayment of a claim against provider’s current claim submission when; (i) the provider fails to reimburse the Alliance within the timeframe set forth in above Section, Contested Notice, and (ii) the Alliance’s contract with the provider specifically authorizes the Alliance to offset an uncontested notice of overpayment of a claim from the provider’s current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider’s current claim or claims pursuant to this section, the Alliance will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims.