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

Community Health Center Network
Phone Number: 1.510.297.0220
Fax: 1.510.297.0222

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).

Gửi ủy quyền

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.

Từ chối và kháng cáo

All utilization review decisions to deny coverage are made by the Alliance team of Medical Directors. In certain circumstances, an external review of service requests may be conducted by qualified licensed physicians with the appropriate clinical expertise.

Denial notifications are sent to the requesting provider via fax and mailed to the member. The denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline for which the denial decision was made and directions on how to obtain a copy of the reference.

It is also our policy to make an appropriate practitioner reviewer available to discuss any denial decision with the requesting provider. The denial notification will include the Alliance UM Department peer-to-peer phone line information.

Providers can submit an appeal by contacting:

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

For more information please view Grievances & Appeals.

Đánh giá nội trú

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.