Pre-approval (prior authorization)

For some types of care, your primary care provider (PCP) or specialist will need to ask the Alliance for permission before you get the care. This is called asking for prior authorization, prior approval, or preapproval. It means that the Alliance must make sure that the care is medically necessary or needed. Medically necessary services are reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or reduce severe pain from a diagnosed disease, illness or injury. For members under the age of 21, Medi-Cal services includes care that is medically necessary to fix or help relieve a physical or mental illness or condition.

The following services always need pre-approval (prior authorization), even if you get them from a provider in the Alliance network:

• Hospitalization, if not an emergency • Services out of the Alliance service area, if not an emergency or urgent
• Outpatient surgery • Long-term care at a nursing facility • Specialized treatments • Medical transportation services when it is not an emergency. Emergency ambulance services do not require pre-approval.
• Outpatient diagnostic and radiology services, minimally invasive or invasive, such as CT scans, MRIs, cardiac catheterization, PET
• Home Health Care, including skilled nursing, nursing aides, rehabilitation therapies, and social workers

Under Health and Safety Code Section 1367.01(h)(1), the Alliance will decide routine pre-approvals (prior authorizations) within five (5) working days of when the Alliance gets the information reasonably needed to decide.

For requests that a provider indicates, or the Alliance determines that following the standard time frame could seriously endanger your life or health or ability to attain, maintain, or regain maximum function, the Alliance will make an expedited (fast) pre-approval (prior authorization) decision. The Alliance will give you notice as quickly as your health condition requires and no later than 72 hours after getting the request for services.

Pre-approval (prior authorization) requests are reviewed by clinical or medical staff, such as doctors, nurses and pharmacists. The Alliance does not pay the reviewers to deny coverage or services. If the Alliance does not approve the request, the Alliance will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision. The Alliance will contact you if the Alliance needs more information or more time to review your request.

You never need pre-approval (prior authorization) for emergency care, even if it is out of the network and out of your service area. This includes labor and delivery if you are pregnant.

You do not need pre-approval (prior authorization) for sensitive services, such as family planning, HIV/AIDS services, and outpatient abortions. For questions about pre-approval (prior authorization), call:

• Alliance Member Services Department
• Monday – Friday, 8 am – 5 pm
• Phone Number: 1.510.747.4567
• Toll-Free: 1.877.932.2738
• People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Pre-Service Authorizations

The Alliance Utilization Management (UM) Department must review and approve some types of care before they are provided. Your primary care provider (PCP) or specialist will work with the Alliance UM to get pre-service authorizations. The Alliance UM clinical review team of doctors determine whether the service is clinically appropriate, performed in the appropriate setting, and a part of your covered benefits.

Your PCP or specialist will give the Alliance UM team the clinical information that is needed for all services that require a medical necessity review. Your PCP or specialist must select the “Type of Request” on the Prior Authorization (PA) Request Form.

Your PCP or specialist must also include all supporting clinical information with the initial request to help ensure a timely decision. If the clinical review information is not received with the PA Request Form, the Alliance UM team will contact your PCP or specialist to collect the needed information.

Clinical information about a member may include:

• Consultations
• Diagnostic results
• History of presenting problem
• Member’s response to treatment
• Photographs
• Physical assessment
• Previous and current treatment

Your PCP or specialist should provide clinical information at least five (5) days prior to the planned service date to ensure timely notification of coverage approval. Your PCP or specialist is responsible for obtaining authorization. Your PCP or specialist must provide an authorization reference number on all referrals and claims.

Post-Service/Retrospective Review

The Alliance post-service retrospective review is the process that the Alliance Utilization Management (UM) team works with your PCP or specialist to determine medical necessity or coverage under the health plan benefit. Post-service retrospective authorizations will only be considered if submitted within 90 days of the date of service.

At the Alliance, we are here to help. As your partner in health, we strive to connect you to the right care at the right time. If you have a health concern, please call your doctor any time, 24 hours a day, 7 days a week.

Your Doctor

Call your doctor’s office or clinic for advice. Doctors expect to get phone calls at night or on weekends. They set up their practices to receive your calls at times when they are not open. Your doctor can help you decide if you really need to go to the emergency room, or can give you advice about what to do at home that can get you or your child through the night or weekend.

Advice Nurse Line

If you can’t reach your doctor, the nurse line is ready to give you advice, any time, 24 hours a day, 7 days a week.
Please call:

Toll-Free: 1.888.433.1876

Key features of the Advice Nurse Line:

• No cost for Alliance Members.
• Ready to help 24 hours a day, 7 days a week.
• Nurses provide advice on topics, such as:
  • Treatment of common health concerns
  • Tips on leading a healthy lifestyle
  • Health screenings and shots
• Nurses help you decide whether you require emergency or urgent care, or if you should schedule a doctor’s visit.
• Nurses speak English and Spanish, and use interpreters for other languages.
• For more information, please select your preferred language:
  English | Spanish | Chinese | Vietnamese | Tagalog

Urgent Care

Your doctor or the advice nurse line may direct you to an urgent care clinic. Many clinics are open late, on weekends and holidays. To find an urgent care clinic in the Alliance network, please search our online Alliance Provider Directory.

To view a copy of the Alliance Medi-Cal Provider Directory, please click here.

Alliance Medi-Cal members who have developmental disabilities may receive counseling, support, and other non-medical services, such as respite care, out-of-home placement, and arrange for supportive living services from the Regional Center of the East Bay.

Examples of developmental disabilities are:

• Autism
• Cerebral palsy
• Epilepsy
• Mental retardation
• Significant delays in development

To learn more, please call:

Regional Center of the East Bay
Phone Number: 1.510.618.6100

As an Alliance member, you have access to behavioral health care services. Prior authorization (approval) is not required for routine outpatient behavioral health care services. The Alliance also covers all substance use disorder (SUD) services.

To find a behavioral health care provider in our network, please click here.

Alcohol and Substance Use Disorder (SUD) Services

The Alliance covers:

• Alcohol misuse screening and counseling
• Hospital stays medically necessary to treat withdrawal symptoms
• Non-medical transportation to alcohol and substance use disorder treatment

Outpatient Behavioral Health Care Services

The Alliance covers:

• Outpatient laboratory, drugs, and supplies
• Outpatient services for monitoring drug therapy
• Psychiatric consultation
• Psychological testing
• Psychotherapy

Pediatric Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

As an Alliance Medi-Cal member, you have access to Pediatric Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.

For more information, please view your Alliance Medi-Cal Member Handbook.

Specialty Mental Health Services (SMHS)

If your behavioral health screening results determine you need specialty mental health services (SMHS), your doctor will refer you to the county to receive an assessment.

SMHS is a program offered to Medi-Cal patients who meet medical necessary criteria.

SMHS may include the following services:

• Inpatient Services
  • Acute psychiatric inpatient hospital services
  • Psychiatric inpatient hospital professional services
  • Psychiatric health facility services

• Outpatient Services
  • Crisis intervention services
  • Crisis stabilization services
  • Day rehabilitation services
  • Day treatment intensive services
  • Intensive care coordination (ICC)
  • Intensive home-based services (IHBS)
  • Medication support services
  • Behavioral health care services (assessments, plan development, therapy, rehabilitation, and collateral)
  • Targeted case management services
  • Therapeutic behavioral services
  • Therapeutic foster care (TFC)

• Residential Services
  • Adult residential treatment services
  • Crisis residential treatment services

For  more information on SMHS provided by the county behavioral health care plan, please can call the county. To locate all counties toll-free telephone numbers online, please visit California Department of Health Care Services (DHCS).

For more information on services, please visit Alameda County Behavioral Health Care Services’ (ACBHCS) ACCESS Program.

To learn more about your benefits and covered services, please view your Alliance Medi-Cal Member Handbook.

As an Alliance Medi-Cal member, you may receive dental benefits through the Medi-Cal dental program, Denti-Cal. Please note that authorization from the Alliance may be required.

To learn more about your benefits and covered services, or find a dental provider, please contact:

Denti-Cal
Toll-Free: 1.800.322.6384
People with hearing and speaking impairments (TTY): 1.800.735.2922
www.denti-cal.ca.gov

To learn more about your benefits and covered services, please view your Alliance Medi-Cal Member Handbook.

As an Alliance Medi-Cal member, the Alliance covers the purchase or rental of medical supplies, equipment and other services only when medically necessary and with a prescription from a doctor. These services require an authorization from the Alliance. Durable medical equipment (DME) and medical supplies are provided by the Alliance’s contractor, California Home Medical Equipment (CHME).

To learn more about your benefits and covered services, please view your Alliance Medi-Cal Member Handbook.

As an Alliance Medi-Cal member, your routine vision exams are covered. The Alliance covers routine eye exam and eyeglasses every once in 24 months. These services are offered through our delegated provider, March Vision. You can schedule an eye exam without a doctor’s referral.

For help finding an eye doctor, please contact:

March Vision Care
Toll-free: 1.844.336.2724
www.marchvisioncare.com/find.aspx
Let March Vision Care know you are an Alliance Medi-Cal member.

To learn more about your benefits and covered services, please view your Alliance Medi-Cal Member Handbook.

The Alliance wants to help you get health care services and member materials in your preferred language and format.

Our staff can help you find a doctor who speaks your language or make sure you have an interpreter when you need one. We offer interpreter services in your language at no cost to Alliance members, 24 hours a day, 7 days a week. Aids and services for people with disabilities, like documents in braille and large print, are also available.

To learn more, please click here.

If you are no longer able to safely live in your home due to a health condition, we will provide you with continued care in long-term care facility, subacute facility, or intermediate care home. This service is a part of what is called the Long-Term Care (LTC) benefit.

These places provide care 24 hours a day for people who cannot be at home but do not need to be in the hospital.

The services provided under the Long-Term Care benefit may include:

• Nursing care to help with bathing, eating, and getting dressed.
• Your room and meals
• Tests you may need (x-rays or lab work)
• Therapy to help you be able to talk, move around, and take care of yourself.
• Medicine that your doctor orders

If you live in a long-term care facility, subacute facility, or intermediate care home now, you can remain there if you meet criteria. The Alliance will work with your doctor and the residence to coordinate your care. If your long-term care facility, subacute facility, or intermediate care home is outside of Alameda County, and you just joined our plan, you may continue to stay for another 12 months. At that time, we will work with your doctor to transfer your medical benefits to the county where you are located.

If you have questions about long-term care and services, please call:

• Alliance Member Services Department
• Monday – Friday, 8 am – 5 pm
• Phone Number: 1.510.747.4567
• Toll-Free: 1.877.932.2738
• People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

LTC Member Resources

Long-Term Care Services (LTC) Member Frequently Asked Questions (FAQs)

English | Spanish | Chinese | Vietnamese | Tagalog

Subacute Services for Medi-Cal Members Member Frequently Asked Questions (FAQs)

English | Spanish | Chinese | Vietnamese | Tagalog | Arabic

Transportation services are offered through the Alliance’s transportation provider, ModivCare. There is no cost when transportation is authorized by the Alliance.

Non-Medical Transportation (NMT)

The Alliance allows you to use a car, taxi, bus or other public/private way of getting to your medical appointment for Medi-Cal-covered services. The Alliance provides mileage reimbursement when transportation is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers or train tickets. The Alliance allows the lowest cost NMT type that meets your medical needs.

You can use non-medical transportation (NMT) when you are:

• Picking up prescriptions and medical supplies.
• Traveling to and from an appointment for a Medi-Cal-covered service authorized by your provider.

Non-Emergency Medical Transportation (NEMT)

You are entitled to use non-emergency medical transportation (NEMT) when you physically or medically are not able to get to your medical, dental, mental health and substance use disorder appointment by car, bus, train or taxi, and the Alliance pays for your medical or physical condition. Before getting NEMT, you need to request the service through your doctor, and they will prescribe the correct type of transportation to meet your medical condition.

NEMT must be used when:

• It is approved in advance by the Alliance with a written authorization by a doctor.
• It is physically or medically needed as determined with a written authorization by a doctor; or you are not able to physically or medically use a bus, taxi, car or van to get to your appointment.
• You need help from the driver to and from your residence, vehicle or place of treatment due to a physical or mental disability.

To arrange or follow up on a request for transportation, please call:

Alliance Transportation Services
Toll-Free: 1.866.791.4158

Please call at least three (3) business days before your appointment. Your doctor will be required to submit documentation in order to process the request. For urgent appointments, please call as soon as possible. Please have your Alliance member ID card ready when you call.

Emergency Transportation Services

The Alliance covers ambulance services to help you get to the nearest place of care in emergency situations. This means that your condition is serious enough that other ways of getting to a place of care could risk your health or life. This includes ambulance transportation services provided through the “911” emergency response system. No services are covered outside the U.S., except for emergency services that require you to be in the hospital in Canada or Mexico.

Forms

Physician Certification Statement (PCS) Form:

Please have your doctor complete the form and submit it to the Alliance before you request Non-Emergency Medical Transportation (NEMT):
English | Spanish | Chinese | Vietnamese | Tagalog

Consent for Minor Travel Without Guardian Form

The Alliance offers unaccompanied minors transportation to medical appointments or to obtain other covered medical services.

Parent/authorized guardian, please complete the form below to provide consent for the Alliance to work on the State’s behalf to provide transportation for the minor(s):
English | Spanish | Chinese | Vietnamese | Tagalog

Resources

Medi-Cal Transportation Benefit

English | Spanish |Chinese| Vietnamese | Tagalog

To learn more about your benefits and covered services, please view your Alliance Medi-Cal Member Handbook.