Via Mail:
• Medical Claims for Alliance Members should be submitted for payment as follows:
  
  
  • If the Member/Patient is assigned to an Alliance Primary Care Physician, submit claims to:
    Alameda Alliance for Health
    P.O. Box 2460
    Alameda, CA 94501-0460
  
  
  • If the Member/Patient is assigned to a Children's First Medical Group (CFMG) Primary Care Physician, submit claims to:
    Children's First Medical Group
    P.O. Box 3359
    Oakland, CA 94609
  
  
  • If the Member/Patient is assigned to a Community Health Center Network (CHCN) Primary Care Physician, submit claims to:
    Community Health Center Network
    101 Callan Ave., 3rd Floor
    San Leandro, CA 94577
  
  
• Hospital/Facility Claims for Medi-Cal Members assigned to a Children's First Medical Group (CFMG) Primary Care Physician should be submitted for payment to:
  Children's First Medical Group
  P.O. Box 3359
  Oakland, CA 94609


• Hospital/Facility Claims for all other Alliance Members should be submitted for payment to:
  Alameda Alliance for Health
  P.O. Box 2460
  Alameda, CA 94501-0460


• Mental Health Claims for Alliance Members should be submitted for payment to:
  PacifiCare Behavioral Health
  P.O. Box 31053
  Laguna Hills, CA 92654-1053


• Vision Care Claims for Alliance Medi-Cal Members should be submitted for payment to:
  March Vision Care
  6701 Center Drive West Suite 790
  Los Angeles, CA 90045</li>
  
  Via EDI:
  
• Providers interested in submitting claims electronically should contact Claims Customer Service at 510-747-4530 for additional information.


• Claims that require attachments may not be sent electronically. They must be submitted on the appropriate paper claim form with the attachments.

• Patient Name
• Insured's Identification Number
• Provider's Name
• Date of Birth of Patient
• Date of Service of the Claim
• Billed Charges
• Provider's Tax Identification Number

• All Claims must be submitted timely:
  • Participating (contracted) providers must submit claims within 180 calendar days post-service, or post-EOB if other coverage exists.
  • Non-Participating (non-contracted) providers must submit claims within 365 calendar days post-service, or post-EOB if other coverage exists.

• Certified mail receipt proving claims were received by the Alliance.
• Copy of the Remittance Advice or Evidence of Benefits (EOB) from the primary payer indicating the date of resolution (payment, date of contest, denial, or notice) when the claim was denied for timely EOB.
• Copy of the Alliance's Electronic Data Interchange (EDI) Preprocessing Error Report for claims originally submitted electronically.
• Copy of the Alliance's Remittance Advice (RA) indicating the date and reason for the original denial when a claim was denied for incomplete reasons.
• Documentation of the cause for the delay in submitting a claim to the Alliance when the provider experiences exceptional circumstances beyond his/her control.

• Alliance follows NCCI (National Correct Coding Initiatives) for coding purposes unless otherwise indicated.
• Anesthesia Services are to be reported by use of the Level I CPT 5-digit anesthesia procedure code (00100-01999), plus modifier codes as defined in the Anesthesia Guidelines of the AMA Current Procedural Terminology.
• Alliance updates all systems annually for new codes. New codes will be effective and accepted by Alliance January 1st of each year, following announcement of the new code.
• Level II HCPCS Temporary Codes will be reimbursed at 20% of Billed Charges.

• Must be submitted on a standard current version of a CMS 1500, CMS-1450 (UB04), or the ANSI X12-837-4010A1 (current version electronic format)
• Must contain appropriate information in all required fields.
• Must be a claim for an Alliance member eligible at the time of service. (Always verify eligibility via the Alliance web portal or calling Member Services.)
• Must contain correct current national standard coding, including but not limited to CPT, HCPCS, Revenue, and ICD-9 codes.
• Must not be altered by handwritten additions to procedure codes and/or charges.
• Must be signed, if paper.
• Must be printed with dark ink that is heavy enough to be electronically imaged, if submitted as a paper claim.
• Level III HCPCS (Local Codes) will be accepted in accordance with the State of California's DHS transition plan to Level II HCPCS and CPT Coding.
• California regulations require that claims for sterilization services for Medi-Cal Members, including services for tubal sterilization, vasectomy, and hysterectomy, must be accompanied by the PM330, signed by the Member a minimum of 30 days prior to the date of surgery. Consequently, Alliance will not reimburse professional or facility fees associated with sterilization services unless an appropriately completed consent form is submitted by the primary surgeon; claims submitted without this form will be denied for payment.
• Medi-Cal CHDP providers must submit the PM160 for all CHDP preventive services for Alliance Medi-Cal members between 0-21 years of age along with the CMS 1500 form.
• Initial visit for prenatal care must provide the Last Menstrual Period (LMP) in order to be paid for the service. If billing on a CMS 1500-0805 format, you must indicate the LMP in box 14. If billing in an 837P electronic format you must indicate the LMP in loop 2300, DTP segment, with '484 - Last Menstrual Period' qualifier (Example: DTP]484]D8]19961113~). Without this information, the claim may be denied and provider will be required to submit paper corrected claim.

• Laboratory/Pathology Services: Except for Emergency and Urgent Care Services, and those lab services identified as covered under Primary Care Physician Capitation or specifically identified as reimbursed fee-for-service, laboratory services are carved out to the Health Plan's Capitated Laboratory Provider, Quest Diagnostics. Pathology services, identified as CPT-4 Procedure Code range 88300-88399, are payable by the Health Plan only when performed in conjunction with emergency or urgent care services, or surgical services performed in an in-patient hospital, out-patient hospital, or free-standing surgical facility setting.
• Routine newborn inpatient care: Authorization is no longer required to provide inpatient services related to routine newborn diagnosis. If the newborn is a sick baby, the authorization must be submitted for both the facility and the professional inpatient services. Additionally, any professional service provided by a non-par provider is no longer required to submit authorization related to routine newborn services.

i. If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from AAH to a contracted provider the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;

ii. If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider's position on such issue; and

iii. If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service and provider's position on the dispute, and an enrollee's written authorization for provider to represent said enrollees.

• Electronic provider disputes will be acknowledged within two (2) working days of the date of receipt.
• Paper provider disputes will be acknowledged within fifteen (15) working days of the date of receipt.

• Sort provider disputes by similar issue
• Provide cover sheet for each batch
• Number each cover sheet
• Provide a cover letter for the entire submission describing each provider dispute with
• References to the numbered coversheets.

i. If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from the Alliance to provider the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect;

ii. If the non-contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service, provider's position on the dispute, and an enrollee's written authorization for provider to represent said enrollees.