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Provider Manual

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New & Retired Alliance Provider Manual Policies

Policy Number	Title	Status	Approval Date
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
401-3109	Comprehensive Tobacco Cessation Services	Approved	5/21/2024
401-1505	Childhood Preventive Care	Approved	5/17/2024
401-1505	Attachment A - AAP Recommendations for Preventive Pediatric Health Care	Approved	5/17/2024
401-1505	Attachment B - CA Pediatric TB Risk Assessment	Approved	5/17/2024
401-1509	Timely Access to Care	Approved	5/17/2024
401-1511	Initial Health Appointment	Approved	5/17/2024
401-1515	Nurse Midwife Scope of Practice and Supervision	Approved	5/17/2024
401-1502	Adult Preventive Care	Approved	5/16/2024
401-1502	Attachment A - Guidelines and Recommendations	Approved	5/16/2024
401-1501	Standards of Care	Approved	5/15/2024
404-1109	Disclosure of Utilization Management Process to Providers, Members and the Public	Approved	5/15/2024
401-1101	Quality Improvement & Health Equity Transformation Program	Approved	5/14/2024
401-1201	Quality Improvement Health Equity Committee	Approved	5/14/2024
404-1306	Extended and Standing Referral Authorizations	Approved	5/14/2024
300-4103	Fair Hearing Process for Adverse Decisions	Approved	5/13/2024
600-1001	Claims Processing	Approved	5/13/2024
403-1142	Biosimilars	Approved	5/9/2024
404-1527	Palliative Care	Approved	5/7/2024
404-1112	Medical Necessity - The Definition and Application of Medical Necessity Provision to Authorization Requests	Approved	5/3/2024
600-1006	Breast Pumps and Coordination of Benefits	Approved	4/24/2024
600-1009	Corrected Claim Submissions	Approved	4/24/2024
600-1013	Billing Epidural, Subarachnoid and Nerve Block Injections for Postoperative Pain Management	Approved	4/24/2024
404-1702	Provision of Family Planning Services to Members	Approved	4/19/2024
600-1010	Miscellaneous Drugs and Medical Supplies	Approved	4/16/2024
600-1011	Surgical Implantable Devices Billed with HCPCS Z7610, Miscellaneous Drugs and Medical Supplies Administered	Approved	4/16/2024
600-1016	Non-Covered Service Billed with GA, GY and GZ Modifiers to Medicare	Approved	4/16/2024
600-1019	Modifier 99 (Multiple Modifiers - Not Recognized)	Approved	4/16/2024
105-3003	Suspended or Ineligible Providers	Approved	4/11/2024
404-1201	Authorization Request Process	Approved	4/11/2024
600-1017	Provider Inquiry and Dispute Resolution	Approved	4/11/2024
600-1048	Manual Pricing of a Claim When There is No Medi-Cal Rate	Approved	4/11/2024
600-2314	Proposition 56 Directed Payment Programs Policy	Approved	4/11/2024
404-1520	Administrative Day Criteria	Approved	4/10/2024
404-1603	Medical Supplies Authorizations	Approved	3/19/2024
408-1305	Behavioral Health Services	Approved	3/18/2024
405-1308	Enhanced Care Management Overview	Approved	3/5/2024
404-1726	Non-Emergency Medical Transportation	Approved	3/4/2024
403-1103	Pharmacy Authorization Request Review Process	Approved	2/29/2024
403-1136	Enteral Nutrition Products	Approved	2/29/2024
403-1149	Medical Nutrition Therapy	Approved	2/29/2024
405-1319	Screening and Referral of Medically Eligible Children to California Children’s Services (CCS) Program	Approved	2/29/2024
300-4195	Provider Training and Payment for Annual Cognitive Health Assessments	Approved	2/27/2024
404-1101	Utilization Management Program	Approved	2/27/2024
404-1102	Inpatient Review	Approved	2/27/2024
404-1527	Palliative Care	Approved	2/27/2024
404-1710	Pediatric Therapies for Medi-Cal Recipients	Approved	2/27/2024
404-1724	Hospital Transportation from PCP Office	Approved	2/27/2024
404-1731	Medication Assisted Treatment	Approved	2/27/2024
200-5000	Administrative Member Status - Medi-Cal Members	Approved	2/26/2024
404-1114	Continuity of Care	Approved	2/23/2024
404-1303	Referral Consultation Request Process	Approved	2/23/2024
404-1524	Long-Term Care for Medi-Cal Members	Approved	2/23/2024
404-1715	Genetic Testing	Approved	2/23/2024
405-1313	Adult Complex Case Management	Approved	2/23/2024
300-4045	Doula Requirements	Approved	2/22/2024
404-1112	Medical Necessity - The Definition and Application of Medical Necessity Provision to Authorization Requests	Approved	2/22/2024
404-1521	Hospital Stays Where Discharge, Death or Transfer Occurs on the Day of Admission	Approved	2/22/2024
401-1523	NPMP Scope of Practice and Supervision	Approved	2/21/2024
300-3090	Updates to Provider Manual	Approved	2/20/2024
300-9010	Review Procedure for Decisions Concerning Provider Network Participation	Approved	2/20/2024
401-1101	Quality Improvement & Health Equity Transformation Program	Approved	2/20/2024
105-3001	Program Integrity: Fraud, Waste & Abuse Prevention Program	Approved	2/15/2024
600-1001	Claims Processing	Approved	2/9/2024
401-1506	Immunization Services and Reimbursement	Approved	2/7/2024
300-4035	Community Health Workers Requirements	Approved	1/31/2024
404-1202	After-Hours Availability of Plan or Contract Physician	Approved	1/26/2024
401-1509	Timely Access to Care	Approved	1/22/2024
401-1519	Infection Control Practices	Approved	1/18/2024
401-1201	Quality Improvement Health Equity Committee	Approved	1/17/2024
405-1108	Medi-Cal Home and Community Based Services (HCBS) Waiver Programs	Approved	1/12/2024
401-1514	In-Office Telephone Triage	Approved	1/11/2024
401-1705	Care-Based Incentive Program	Approved	1/10/2024
600-2314	Proposition 56 Directed Payment Programs Policy	Approved	1/9/2024

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