For assessment and treatment as medically necessary.
Submit this form for any non-formulary anti-obesity agent medication.
Providers can use this form to check the status of an authorization request.
Providers can complete this form to refer a member to local behavioral health care coordination services.
Completed by physician, pediatrician, neurologist or licensed clinical psychologist (M.D./D.O./Ph.D./Psy.D.).
Providers can use this form to request clinical decision support, behavioral health treatment/applied behavioral analysis services, or to refer a member for outpatient behavioral health or care management services.
Providers can use this form to request clinical decision support, behavioral health treatment/applied behavioral analysis services, or to refer a member for outpatient behavioral health services. The form includes a page in Spanish for members to authorize sharing of information between their behavioral health provider and PCP.
These advance directive forms are easy for patients to read and understand.
Providers can use this form for referrals to Care Management (CM) Services, including Complex Case Management and Care Coordination.
Providers can send this form to the Alliance with their signed Services Agreement.
Providers receiving payments under a Services Agreement of $100,000 or more are required to submit the Certification Regarding Lobbying form to the Alliance.
For assessment and treatment as medically necessary.
If you are interested in becoming an Alliance-approved clinical health education (CHE) provider, submit this application.
Providers can use this form to inquire about CBAS services for Alliance members.
Providers can use this sample form to obtain consent for sterilization or a hysterectomy. Providers are free to duplicate this form and add their letterhead.
Providers can use this form to submit corrected claims. The form must be completed in full and the claim must be attached. To prevent delays in processing, please do not staple the claim to the form.
Providers can use this form to check if a CPT code requires prior authorization.
Participating hospital providers are required to complete and submit this form to the Alliance on a quarterly basis.
Refer to the DHCS Facility Site Review (FSR) Checklist to help prepare for facility site reviews.
Refer to the DHCS Medical Record Review (MRR) Checklist to help prepare for medical record reviews.
This application is used to enroll providers as Trading Partners for various EDI transactions, such as 837 Electronic Claims Submission, 835 Electronic Remittance Advice and others.
Prior approval is required to access all face-to-face interpreter services.
Please complete the self-assessment of your facility’s compliance to the DHCS Critical Element Criteria.
To refer an Alliance member to one of our programs, please complete the Health Programs Referral Form and fax it to Alliance Health Programs.
Use this resource for HCV medication requests.
Use this form for opioid drugs that exceed our quantity limits.
Providers and community partners can use this form to request that the Alliance release information related to an Alliance member that is considered to be protected health information (PHI). The form is available in English, Spanish and Hmong.
To report any concerns or issues with our language assistance services, please complete our Interpreter Services Quality Assurance Form.
Providers can use this form to notify the Alliance of all locum tenens before they render services to Alliance members. Locum tenens are providers who temporarily take the place of, or cover, for another provider.
Providers can use this form to request authorization for long term care.
Providers are required to report provider-preventable conditions to DHCS within five working days of discovery via their secure online reporting portal.
Dental providers can use this form to obtain feedback from an Alliance member’s primary care provider (PCP) regarding the use of general anesthesia or IV sedation for dental procedures.
Primary care providers may use this form to create a Medication Management Agreement for their members. Forms are available in English, Spanish and Hmong.
Providers can use this form to inform the Alliance Member Services department that an Alliance member did not keep a scheduled appointment. Providers can also quickly report member no-shows on the Alliance Provider Portal.
Providers can use these templates to notify members when a reassignment has been requested. Templates are available in English, Spanish and Hmong.
After reviewing the information acknowledge that you have completed the training. Please note that the review must be completed prior to the 10th business day of the month.
Providers can use the OHC Referral Form to report an Alliance member’s other health coverage.
Providers can use this form to track patient requests for complaint/grievance forms.
Providers can enroll members in the Pharmacy Home Program to lock prescription dispensing of any or all drugs to one pharmacy provider for a period not to exceed 12 months. This elective program may be considered as an additional tool in managing patients considered at risk for opioid misuse or abuse.
Providers are required to complete this form for each member requiring non-emergency medical transportation (NEMT) before transportation can be approved.
The Alliance encourages providers to have conversations on end-of-life planning that occurs with seriously ill patients, allowing them to choose the treatments they want and helping ensure that their wishes are honored by medical providers.
Beginning April 1, 2021, prior authorization requests for all Alliance members must be submitted by completing the Prescription Drug Prior Authorization or Step Therapy Exception Request Form.
Use this form for chemotherapy, HCPCS J-code requests and other IV medication requests administered by the physician/hospital.
Contracted providers can use this form to request reimbursement rate information from the Alliance. Please read the instructions tab in its entirety prior to filling out and submitting the form.
Providers can use this form to make simple changes to an existing prior authorization.
Providers can use this form to report an overpayment made by the Alliance.
Providers can use this form to file a dispute with the Alliance.
In order to set up a Provider Portal account, providers are required to read and accept the Health Information Sharing Agreement.
Use to order bulk quantities of the SHA forms and patient handouts in English, Spanish and Hmong. Remember to use the SHA during the Initial Health Assessment (IHA) and subsequent well exams.
Providers who wish to administer Synagis in their office are required to submit the Statement of Medical Necessity along with the prior authorization request.
Use this form to communicate the need for regimen continuation.
Providers can use this form to request non-emergency medical transportation (NEMT) for Alliance members.
Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.
Contact Provider Services
Billing questions, claims status, general claims information
General authorization information or questions
Checking the status of submitted authorizations
Authorizations, general pharmacy information or questions