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Provider Manual

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New & Retired Alliance Provider Manual Policies

Policy Number	Title	Status	Approval Date
404-1310	Attachment A - Requirements for Referral of Members to Specialty Providers	Approved	4/8/2025
404-1720	Private Duty Nursing EPSDT Benefit	Approved	4/7/2025
404-1732	Meals and Lodging ("Maintenance") and Related Expenses for Members	Approved	4/7/2025
405-1313	Adult Complex Case Management	Approved	4/7/2025
404-1101	Utilization Management Program	Approved	3/31/2025
404-1708	Chiropractic Services for Alliance Members	Approved	3/31/2025
300-4195	Provider Training and Payment for Annual Cognitive Health Assessments	Approved	3/25/2025
404-1525	Skilled Nursing Program Policy for Medi-Cal	Approved	3/25/2025
404-1726	Non-Emergency Medical Transportation	Approved	3/25/2025
405-1317	Early Intervention Services	Approved	3/25/2025
404-1114	Continuity of Care	Approved	3/19/2025
405-1108	Medi-Cal Home and Community Based Services (HCBS) Waiver Programs	Approved	3/19/2025
404-1524	Long-Term Care for Medi-Cal Members	Approved	3/17/2025
408-1305	Behavioral Health Services	Approved	3/13/2025
408-1309	DHCS Non-Specialty Mental Health Services: Member Outreach, Education and Experience Requirements	Approved	3/13/2025
105-3003	Suspended or Ineligible Providers	Approved	3/12/2025
404-1108	Monitoring of Over/Under Utilization of Services	Approved	3/7/2025
200-5000	Administrative Member Status - Medi-Cal Members	Approved	2/28/2025
404-1724	Hospital Transportation from PCP Office	Approved	2/28/2025
600-1001	Claims Processing	Approved	2/28/2025
600-1050	Implementation of Medi-Cal Rates	Approved	2/28/2025
403-1103	Pharmacy Authorization Request Review Process	Approved	2/26/2025
403-1141	Physician/Facility-Administered Drugs Requiring Prior Authorization	Approved	2/26/2025
403-1142	Biosimilars	Approved	2/26/2025
403-1146	Drug Waste Reimbursement	Approved	2/26/2025
405-1318	Pediatric Complex Case Management	Approved	2/26/2025
405-1312	Primary Care Provider Responsibilities Including Case Management and the Promotion of Patient Centered Medical Home	Approved	2/25/2025
300-4025	Provider Screening and Enrollment Guidelines	Approved	2/20/2025
300-4045	Doula Requirements	Approved	2/19/2025
404-1307	Medical Second Opinions	Approved	2/19/2025
401-1101	Quality Improvement & Health Equity Transformation Program	Approved	1/22/2025
403-1136	Enteral Nutrition Products	Approved	1/22/2025
404-1102	Inpatient Review	Approved	1/22/2025
404-1710	Pediatric Therapies for Medi-Cal Recipients	Approved	1/22/2025
404-1714	Technology Assessment	Approved	1/22/2025
404-1109	Disclosure of Utilization Management Process to Providers, Members and the Public	Approved	1/21/2025
404-1702	Provision of Family Planning Services to Members	Approved	1/16/2025
404-1731	Medication Assisted Treatment	Approved	1/16/2025
404-1738	Community Health Worker Services	Approved	1/16/2025
401-1505	Childhood Preventive Care	Approved	1/14/2025
401-1505	Attachment A - AAP Recommendations for Preventive Pediatric Health Care	Approved	1/14/2025
401-1505	Attachment B - CA Pediatric TB Risk Assessment	Approved	1/14/2025
401-1506	Immunization Services and Reimbursement	Approved	1/14/2025
401-1515	Nurse Midwife Scope of Practice and Supervision	Approved	1/14/2025
404-1201	Authorization Request Process	Approved	1/10/2025
404-1309	Member Access to Self Referred Services	Approved	1/8/2025
404-1303	Referral Consultation Request Process	Approved	12/30/2024
460-1308	Enhanced Care Management Overview	Approved	12/30/2024
600-1017	Provider Inquiry and Dispute Resolution	Approved	12/30/2024
600-1040	Unbundled ENT CPT Codes	Approved	12/30/2024
600-1050	Implementation of Medi-Cal Rates	Approved	12/30/2024
600-1072	AB72	Approved	12/30/2024
600-2307	Telehealth Covered Services and Reimbursement	Approved	12/30/2024
600-2308	Family Planning Supplemental Payment Eligibility and Payments	Approved	12/30/2024
600-2314	Proposition 56 Directed Payment Programs Policy	Approved	12/30/2024
300-4103	Fair Hearing Process for Adverse Decisions	Approved	12/23/2024
404-1524	Long-Term Care for Medi-Cal Members	Approved	12/23/2024
404-1525	Skilled Nursing Program Policy for Medi-Cal	Approved	12/23/2024
404-1525	Attachment A - Skilled Nursing Facility Levels of Care Matrix	Approved	12/23/2024
404-1527	Palliative Care	Approved	12/23/2024
404-1726	Non-Emergency Medical Transportation	Approved	12/23/2024
300-9010	Review Procedure for Decisions Concerning Provider Network Participation	Approved	12/20/2024
401-1301	Potential Quality Issue Review Process	Approved	12/20/2024
401-1306	Corrective Action Plan for Quality Issues	Approved	12/20/2024
401-1502	Adult Preventive Care	Approved	12/20/2024
404-1203	Surgical Treament of Varicose Veins	Approved	12/20/2024
300-4180	Training and Payment for Adverse Childhood Experiences Screening	Approved	12/16/2024
300-6030	New Provider Training	Approved	12/16/2024
300-6036	Provider Early and Periodic Screening Diagnostic and Treatment (EPSDT) Training	Approved	12/16/2024
300-1509	Timely Access to Care	Approved	12/13/2024
300-4160	Optometrist Reimbursement for Medical Services	Approved	12/13/2024
300-8030	Monitoring Network Compliance with Accessibility Standards	Approved	12/13/2024
404-1603	Medical Supplies Authorizations	Approved	12/13/2024
404-1715	Genetic Testing	Approved	12/13/2024
404-1601	Durable Medical Equipment (DME) Authorization	Approved	12/10/2024
404-1703	Alliance Members with Veterans Benefits	Approved	12/10/2024
404-1112	Medical Necessity - The Definition and Application of Medical Necessity Provision to Authorization Requests	Approved	12/5/2024
105-3002	Program Integrity: Special Investigations Unit Operations	Approved	12/4/2024
300-4025	Provider Screening and Enrollment Guidelines	Approved	11/15/2024
404-1310	Attachment A - Requirements for Referral of Members to Specialty Providers	Approved	11/7/2024
404-1710	Pediatric Therapies for Medi-Cal Recipients	Approved	11/7/2024
404-1731	Medication Assisted Treatment	Approved	11/7/2024
600-1802	Claims Submission Guidelines and Rental Timeframes for TENS Device	Approved	11/7/2024
600-1803	Claims Submission Guidelines and Rental Timeframes for Wheelchairs	Approved	11/7/2024
600-1804	Claims Submission Guidelines for an Osteogenesis Stimulator	Approved	11/7/2024
404-1601	Attachment A - DME Authorization Matrix Providers	Approved	11/4/2024
403-1136	Enteral Nutrition Products	Approved	10/31/2024
403-1139	Opioid Utilization Review	Approved	10/31/2024
403-1149	Medical Nutrition Therapy	Approved	10/31/2024
404-1707	Acupuncture Services for Medi-Cal Members	Approved	10/31/2024
600-1043	CHDP Crosswalk Code for Snellen	Approved	10/31/2024
600-1044	H0049 and G0442 CHDP Program Reimbursement for Alcohol Misuse Screening	Approved	10/31/2024
600-3004	Credit Balance Report	Approved	10/31/2024
405-1312	Primary Care Provider Responsibilities Including Case Management and the Promotion of Patient Centered Medical Home	Approved	10/30/2024
600-1039	Billing for Time Based Anesthesia Services	Approved	10/22/2024
404-1307	Medical Second Opinions	Approved	10/17/2024
600-1024	Durable Medical Equipment Pricing	Approved	10/17/2024
404-1204	Laparoscopy – Cholecystectomy Authorization Process	Approved	10/16/2024
404-1711	Sleep Study (Polysomnopraphy/Sleep Disorder Testing) Authorization	Approved	10/16/2024
404-1713	Electromyography, Nerve Conduction Studies	Approved	10/16/2024
401-1305	Provider Preventable Conditions	Approved	10/15/2024
401-1305	Attachment A - PPC Worklflow	Approved	10/15/2024
401-1305	Attachment B - Provider Preventable Conditions List	Approved	10/15/2024
401-1705	Care-Based Incentive Program	Approved	10/15/2024
404-1734	Allergy Immunotherapy	Approved	10/15/2024
404-1734	Attachment A: Immunotherapy Authorization Request Checklist	Approved	10/15/2024
401-1101	Quality Improvement & Health Equity Transformation Program	Approved	10/14/2024
401-1523	NPMP Scope of Practice and Supervision	Approved	10/11/2024
405-1313	Adult Complex Case Management	Approved	10/8/2024
600-1036	Modifier Reference Grid	Approved	9/26/2024
600-1036	Attachment A - Modifier Grid	Approved	9/26/2024
600-1801	Claims Submission Guidelines and Rental Timeframes for Nebulizers	Approved	9/26/2024
405-1318	Pediatric Complex Case Management	Approved	9/24/2024
600-1031	Twins Delivery Reimbursement	Approved	9/24/2024
300-4185	Community Supports Encounter Data	Approved	9/16/2024
300-8030	Monitoring Network Compliance with Accessibility Standards	Approved	9/12/2024
404-1201	Authorization Request Process	Approved	8/30/2024
300-1509	Timely Access to Care	Approved	8/29/2024
403-1114	Continuing Pharmacy Care for New Members	Approved	8/22/2024
403-1126	Pharmaceutical Services Access	Approved	8/22/2024
403-1136	Enteral Nutrition Products	Approved	8/15/2024
403-1152	Site of Care	Approved	8/15/2024
300-4035	Community Health Workers Requirements	Approved	8/8/2024
300-8040	Monitoring PCP Capacity	Approved	8/7/2024
403-1145	Pharmacy 340B Program	Approved	8/7/2024
105-3004	Verification of Billed Services by Network Providers	Approved	7/31/2024
405-1111	Community Based Adult Services	Approved	7/30/2024
405-1112	Care Management of Seniors and Persons with Disabilities for Medi-Cal	Approved	7/30/2024
405-1304	Developmental Disabilities - Services to Plan Members	Approved	7/30/2024
404-1738	Community Health Worker Services	Approved	7/29/2024
404-1102	Inpatient Review	Approved	7/23/2024
600-1007	Durable Medical Equipment Rent-to-Purchase Pricing	Approved	7/23/2024
404-1108	Monitoring of Over/Under Utilization of Services	Approved	7/22/2024
401-1510	Medical Record Review and Requirements	Approved	7/17/2024
401-1508	Facility Site Review Process	Approved	7/15/2024
600-1032	Wheelchair/Scooter Repair Mileage and Medicare Denials	Approved	7/15/2024
600-1037	Global Surgery	Approved	7/15/2024
404-1113	External Independent Medical Review	Approved	7/12/2024
404-1202	After-Hours Availability of Plan or Contract Physician	Approved	7/12/2024
401-1514	In-Office Telephone Triage	Approved	7/11/2024
300-8030	Monitoring Network Compliance with Accessibility Standards	Approved	7/10/2024
403-1103	Pharmacy Authorization Request Review Process	Approved	6/28/2024
403-1141	Physician/Facility-Administered Drugs Requiring Prior Authorization	Approved	6/28/2024
105-3002	Attachment A - Anti-FWA Laws and Regulations	Approved	6/27/2024
105-3002	Program Integrity: Special Investigations Unit Operations	Approved	6/27/2024
401-4101	Cultural and Linguistics Services Program	Approved	6/27/2024
401-4103	Interpreter Services	Approved	6/27/2024
300-3090	Attachment B - Quarterly Timeline	Approved	6/24/2024
300-3090	Attachment A - Provider Manual Update Flow Chart	Approved	6/24/2024
405-1314	Transitional Care Services	Approved	6/20/2024
600-1030	Reimbursement for Medicare/Medi-Cal Crossover Nephrology and Dialysis Services	Approved	6/20/2024
600-1033	Wheelchair, Wheelchair Accessories and/or Replacement Parts for Patient-Owned Equipment Pricing	Approved	6/20/2024
600-1029	Orthotics and Prosthetics Pricing	Approved	6/18/2024
600-1022	Charpentier Billing Procedure	Approved	6/12/2024
600-1026	Incontinence and Medical Supply Pricing	Approved	6/12/2024
404-1401	Sterilization Consent Protocol	Approved	6/11/2024
404-1729	Pulmonary Rehabilitation Services	Approved	6/11/2024
404-1714	Technology Assessment	Approved	6/6/2024

Contact Provider Services

General	831-430-5504
Claims Billing questions, claims status, general claims information	831-430-5503
Authorizations General authorization information or questions	831-430-5506
Authorization Status Checking the status of submitted authorizations	831-430-5511
Pharmacy Authorizations, general pharmacy information or questions	831-430-5507