We are here to help you

To receive any of these documents by fax or mail, please contact:

Behavioral Health Care Services Prior Authorization and Referral Forms

The Alliance provides outpatient behavioral health care services. Prior authorization (approval) is not required for routine outpatient behavioral health care services. For Alliance Medi-Cal members, these include mild to moderate mental health conditions. For Alliance Group Care, these include outpatient and specialty mental health services. The Alliance also covers all substance use disorder (SUD) services.

PRIMARY CARE PROVIDER (PCP) REFERRAL FORMS

Alliance Behavioral Health Care Autism Evaluation BHT/ABA Referral Form

Alliance Behavioral Health Care Referral Form

Case and Disease Management (CMDM) Program Referral Form

The Alliance Case and Disease Management (CMDM) Program is available to help you care for your complex patients and is provided at no cost to your patients.

The program coordinates services and provides support to help improve patient outcomes and overall member satisfaction.

FORMS

View and download the CMDM Program Referral Form.

Please Note: The Alliance may also contact the member to see if they would like to enroll. Members may also self-refer.

You can advise your patient to call:

For more information, please view the Case and Disease Management (CMDM) page.

Demographic Attestation Form

In an ongoing effort to provide the highest level of customer service, we ask that you please complete the Provider Demographic Attestation Form when you have changes or updates in your practice. These updates are important to share the accurate information in our provider directory.

FORM

View and download the Provider Demographic Attestation Form.

To view a copy of the Alliance Provider Directory, please select a health care program:
Medi-Cal | Alliance Group Care

Electronic Data Interchange (EDI) Form

Electronic Data Interchange (EDI), is a service for providers to send claims electronically from their Practice Management System to the Alliance. The claims are sent in real-time.

FORM

View and download the EDI Enrollment Form

For more information, please view the EDI page.

Electronic Funds Transfer (EFT) Form

We are pleased to announce the availability of Electronic Funds Transfer (EFT). Providers who enroll in EFT will have fee-for-service (FFS) payments deposited directly into their bank account. The EFT option is available to all contracted providers.

To enroll in EFT, providers must complete the EFT enrollment form.

Health Education Requests Forms

Alliance Wellness Program & Materials Request Form

To request Alliance wellness materials or programs for a member please view Patient Health & Wellness Education.

Interpreter Request Form

The Alliance offers interpreter services, including American Sign Language, for Alliance members who are receiving covered services in non-hospital settings. Hospitals are required to provide interpreter services for patients receiving care at hospital settings.

FORM

View and download the Interpreter Services Guide and Request Form.

For more information, please view the Provider Language Access page.
For member access, please click here.

Long-Term Care (LTC) Forms and Resources

On Sunday, January 1st, 2023, the Alliance started administering the long-term care (LTC) benefit as a part of the statewide California Advancing and Innovating Medi-Cal (CalAIM) goal to standardize benefits and reduce complexity and county-to-county differences across the state. For more information about the LTC carve-in, please refer to the Department of Health Care Services website at www.dhcs.ca.gov/provgovpart/Pages/Long-Term-Care-Carve-In-Transition.aspx.

LTC Forms

Prior Authorization (PA) Request Form

LTC – Authorization Request Form (ARF) for SNF/LTC/Subacute/Hospice Room and Board

LTC – Authorization Request Form (ARF) for Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) Room and Board

LTC Discharge Disposition Form

LTC Rounds Form

Medi-Cal Choice Form

Your patient can select the Alliance as their health plan on the Medi-Cal Choice Form if:

  • They have Medi-Cal.
  • They are eligible to be in a managed care health plan.
  • They live in Alameda County.

If they would like to learn more about eligibility, enrollment, disenrollment, and changing health plans, please have them contact us or call:

Medi-Cal Managed Care/Health Care Options (HCO)
Toll-Free: 1.800.430.4263
People with hearing and speaking impairments (TTY): 1.800.430.7077
www.healthcareoptions.dhcs.ca.gov

HCO is contracted with the state to provide enrollment assistance and can help you select a managed care health plan.

To find a local Alameda County Social Services Agency office, please click here.

FORM

Your patient can view, download, or request a copy of the Medi-Cal Choice Form by visiting the California Department of Health Care Services (DHCS) Medi-Cal Managed Care HCO Program website.

For more information, please visit Alliance Medi-Cal Member Benefits and Covered Services.

Pharmacy & Medication Formulary Forms

Formulary Review Request Form

The Alliance Medication Formulary is a list of medications covered by the Alliance to meet your patient’s needs. This formulary applies to Alliance Group Care.

Providers can submit a completed Formulary Review Request Form to the Alliance Pharmacy & Therapeutics (P&T) Committee for their consideration for review of a medication.

FORM

View and download the Formulary Review Request Form.

Prescription Drug Prior Authorization (PA) Request Form

The Alliance uses a Medication Formulary to provide access to quality and clinically effective medications. Prescribers may submit a Prescription Drug Prior Authorization (PA) Request form to request medication that are not on the Alliance Medication Formulary that requires a prior authorization (PA). Prescribers must use the Prescription Drug PA Request form when submitting a request for review. The medications that require PA are subject to change.

FORM

View and download the Prescription Drug Prior Authorization (PA) Request Form.

Specialty Pharmacy Services Forms

The Alliance expanded to PerformSpecialty services to cover hepatitis C.

FORM

View and download the enrollment form.

To request prior authorization for Hepatitis C (HCV) treatment and medication, please use the HCV Prescription Drug Prior Authorization Form.

For more information, please view below:

Prior Authorization (PA) Request Form

The Alliance UM Department must review and approve select services before they are provided. Clinical review determines whether the service is clinically appropriate, performed in the appropriate setting, and a part of our covered benefits.

Clinical information is necessary for all services that require a medical necessity review. The requesting provider must select the “Type of Request” on the Prior Authorization (PA) Request Form. Providers 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, our UM team will contact the provider to collect the needed information.

FORM

View and download the Alliance Prior Authorization Form.

For more information, please view Pre-Service Authorizations.
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).

Provider Dispute Resolution (PDR) Form

Contracted Provider

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.

Non-Contracted Provider

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.

FORM

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

For more information, please view the Claims page.

Transportation

Physician Certification Statement (PCS) Form:

Please complete this form for your patient and submit it to the Alliance before they request Non-Emergency Medical Transportation (NEMT):
English | Spanish | Chinese | Vietnamese | Tagalog

To view member forms, please click here.