1. Claim Submission Instructions

• A. Submitting Claims to the Alliance
• Providers should review the Alliance member ID card for the claims billing address.
• If sending claims by US Postal Service (USPS), Professional Claims for all Alliance members should be submitted for processing as follows:
• 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 for all Alliance members:
  • Alameda Alliance for Health
  • P.O. Box 2460
  • Alameda, CA 94501-0460
• Mental Health professional claims for mild to moderate services for Alliance Medi-Cal members:
  • Beacon Health Options
  • P.O. Box 1862
  • Hicksville, NY 11802-1862
• Mental Health 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
• Mental Health facility claims for Alliance Medi-Cal members:
  • Alameda County Behavioral Health Care Services
  • Claims Processing Department
  • P.O Box 738
  • San Leandro, CA 94577
• Mental Health claims for Alliance Group Care members:
  • Beacon Health Options
  • P.O. Box 1862
  • Hicksville, NY 11802-1862
• Vision Care claims for Alliance Medi-Cal members:
  • March Vision Care
  • 6701 Center Drive West Suite 790
  • Los Angeles, CA 90045
• Dental claims for Alliance Medi-Cal members:
  • Medi-Cal Dental
  • P.O. Box 15610
  • Sacramento, CA 95852-0610
• Providers interested in submitting claims electronically via Electronic Data Interchange (EDI) should call:
  • Alliance Provider Services Department
  • Monday – Friday, 7:30 am – 5 pm
  • Phone Number: 1.510.747.4510
• To learn more about our EDI services, please click here.
• 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

• Immediate response related to claims or check status can be obtained by Alliance contracted providers using 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. Claim Receipt Verification

• Verification of claim receipt can be obtained online through the Alliance Provider Portal or by calling:
  • Alliance Provider Services Department
  • Monday – Friday, 7:30 am – 5 pm
  • Phone Number: 1.510.747.4510
• The Alliance will acknowledge receipt of paper claims within 15 working days. Claims received electronically will be acknowledged within two (2) working days.

D. Claim Submission Requirements

• Timeframe for Claim Submission
  • Participating (contracted) providers must submit clean claims within 180 calendar days post service, or post date from the Explanation of Benefits (EOB), if other coverage exists.
  • Non-Participating (non-contracted) providers must submit clean claims within 365 calendar days post-service, or post date from the EOB, if other coverage exists.
  • Corrected claim must be submitted correctly for reconsideration of payment within 180 calendar days of the last action. A corrected claim may be mistaken as a duplicate claim submission unless it is clearly identified as such.
• Submitting Claims Outside of the Filing Period
  • If a claim is submitted outside of the timeframes stated above, proper documentation, also known as “proof of timely filing”, must be attached to the late claim.
• Acceptable Proof of Timely Filing Includes
  • • Certified mail receipt proving claims were received by the Alliance.
    • Copy of the Remittance Advice (RA) or EOB from the primary payer indicating the date of resolution (payment, date of contest, denial, or notice) if the claim was denied for untimely EOB.
    • Copy of the Alliance Electronic Data Interchange (EDI) Preprocessing Acceptance or Error Report for claims originally submitted electronically.
    • Copy of the Alliance RA indicating the date and reason for the original denial for unclean claim denials.
    • Documentation/explanation of the cause for the delay in submitting a claim to the Alliance when the provider experiences exceptional circumstances beyond their control.
• Claim Processing Time
  • The Alliance will process all clean claims within 45 working days from receipt.
• Clean Claim
  • A clean claim is defined as a claim which, when it is originally submitted, contains all necessary information, attachments, and supplemental information or documentation needed to determine payer liability, and make timely payment.
• Interest on Claims
  • The Alliance will calculate and automatically pay interest, in accordance with AB1455 and prompt payment requirements, to all providers of service who have not been reimbursed for payment, within 45 working days from the receipt of their clean claim.
• Misdirected Claims
  • When a claim is incorrectly sent to the Alliance that should have been sent to one of its delegated partners (i.e., Community Health Center Network (CHCN),
  • Children’s First Medical Group (CFMG), March Vision), the Alliance will forward the claim to the appropriate delegated partner within ten working days from receipt of the claim. The provider will also receive a notice of denial with instructions to bill the delegated entity.
• Claims Coding
  • The Alliance has a responsibility to control healthcare costs for our providers and for all members. Claims coding and editing enables us to more effectively and universally implement fair reimbursement rules and guidelines aimed at preventing fraud and providing equitable reimbursement to all providers.
    • The Alliance follows the Medi-Cal billing requirements and National Correct Coding Initiatives (NCCI) for coding purposes unless otherwise indicated.
    • Anesthesia services are to be reported by use of the Level I CPT 5-digit anesthesia procedure code (00100-01999), plus modifier codes as defined in the Anesthesia Guidelines of the AMA Current Procedural Terminology.
    • The Alliance updates all systems annually, quarterly, or monthly, as needed, for new codes. New codes will be effective and accepted by the Alliance on the first of the month following announcement or adoption of the new code by Medi-Cal.
• Claim Form Requirements
  • The Alliance has established requirements for filing a claim for payment consideration. Failure to comply with these requirements may impact reimbursement of the claim.
  • To be accepted as a valid claim, the submission must meet the following criteria:
    • Must be submitted on a standard current version of a CMS 1500, CMS-1450 (UB04) or the ANSI X12-837-5010 or most current electronic format.
    • Must contain appropriate information in all required fields.
    • Must be a claim for an Alliance member eligible at the time of service. Providers can confirm a member’s eligibility online through the Alliance Provider Portal or by calling:
      
      • Alliance Provider Services Department
      • Monday - Friday, 7:30 am – 5 pm
      • Phone Number: 1.510.747.4510
      • Email: providerservices@alamedaalliance.org
  • Must contain correct current national standard coding, including but not limited to CPT, HCPCS, Revenue, NDC and ICD-10 codes as well as Medi-Cal Local Codes, as appropriate.
  • Must not be altered by handwritten additions to procedure codes and/or charges.
  • Must be signed by the rendering provider, if submitted as a paper claim.
  • Must be printed with dark ink that is heavy enough to be electronically imaged, if submitted as a paper claim.
  • Level III HCPCS (Local Codes) will be accepted in accordance with the DHCS transition plan to Level II HCPCS and CPT Coding.
  • California regulations require that claims for sterilization services for Medi-Cal members, including services for tubal sterilization, vasectomy, and hysterectomy, must be accompanied by the PM330 form, signed by the member a minimum of 30 days prior to the date of surgery. Consequently, the Alliance will not reimburse professional or facility fees associated with sterilization services unless an appropriately completed consent form is submitted by the primary surgeon. Claims submitted without this form will be denied for payment.
  • Claims billed for office injectables must include properly formatted NDC code and units of measure. Office injectable codes billed without NDC, unit of measure or in an incorrect format will be denied. For additional details, please refer to the Medi-Cal Provider Manual.

• See examples of paper claim submission below.

• NDCs and units billed on CMS1500:

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• NDCs and units billed on CMS1450:

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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.

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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.

II. Dispute Resolution Process for Contracted Providers

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 reasons 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.

G. Non-Contracted Providers Resolution Process for Alameda Alliance Wellness Members

• A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contracted provider completes a waiver of liability statement, which provides that the non-contracted provider will not bill Alameda Alliance Wellness Plan Members. https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/model-waiver-of-liability_feb2019v508.zip 

III. Dispute Resolution Process for Non-Contracted Providers

A. Definition of Non-Contracted Provider Dispute

• A non-contracted provider dispute is a non-contracted provider’s written notice to the Alliance or its delegated group challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: provider name, provider ID number, provider contact information, and:
  • If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from the Alliance to 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, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect;
  • If the non-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, including the date of service, provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.

B. Sending a Non-Contracted Provider Dispute to the Alliance

• Non-contracted provider disputes submitted to the Alliance must include the information listed in Section III.A., above, for each non-contracted provider dispute.
• All non-contracted provider disputes must be mailed or faxed to:
  • Alameda Alliance for Health
  • Attn: Provider Dispute Resolutions (PDR) Unit
  • P.O. Box 2460
  • Alameda, CA 94501-4506
  • Fax: 1.855.891.7173

C. Time Period for Submission of Non-Contracted Provider Disputes

• Non-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.
• Non-contracted provider disputes that do not include all required information as set forth above in Section III.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 Non-Contracted Provider Disputes

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

E. Contact the Alliance Regarding Non-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 Non-Contracted Provider Dispute

• The Alliance will issue a written determination stating the pertinent facts and explaining the reasons for its determination within 45 working days from the date of receipt of the contracted provider dispute or the amended non-contracted provider dispute.
• If the non-contracted provider dispute or amended non-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.

IV. Provider Dispute Resolution Form

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

V. Claim Overpayments

• 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.
• 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 provider dispute resolution process described in Section II above.
• 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 Section V.C., above, 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