Utilization Management

The objective of the Alliance Utilization Management program is to ensure that medical services provided to members are medically necessary and/or appropriate and conform with the benefits of each line of business. Utilization Management is managed by the internal Medical Services Department, consisting of Authorization Specialists, pharmacists, nurses, and physicians. Utilization Management staff consistently apply nationally recognized evidenced-based criteria and consider unique member circumstances when making decisions to approve, modify or deny services.

Alliance Department Phone Fax Email 

Authorizations

510-747-4540

1-855-891-7174

Please do not send PHI by unsecured email.

Grievances & Appeals

510-747-4531

510-995-3705

Member Services

510-747-4567

1-855-891-7172

Provider Services

510-747-4510

1-855-891-7257

providerservices@alamedalliance.org


Authorization Management

For all Alliance lines of business, Medical Services staff at the Alliance manage authorizations for members assigned to directly contracted providers (DCPs).

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. Please see the Delegated Medical Group table below.

You can locate a member’s assigned medical group by referring to the back of the member’s card, logging into the Provider Portal, or calling the Alliance Member Services department. 

Delegated Medical Group Phone Fax  Website 

Children First Medical Group

510-429-3489

510-450-5868

www.children-first-medical.com

Community Health Center Network

510-297-0220

510-297-0222

www.chcnetwork.org 

Provider Portal: https://portal.chcnetwork.org/

For a complete list of services requiring authorization, click here.

For a code specific list of services requiring authorization, click here.

See below for details on the Alliance's various utilization management programs:

Authorization Submission

The Alliance Authorization Request (AAR) form is used for all services requiring prior authorization from the Alliance. The Provider Services department supplies all of the Alliance’s contracted providers with the AAR. Providers may click here for the AAR form or request it from Provider Services. Click here for instructions for filling out the AAR. If you would like to submit a prior authorization for breast pumps, please use the Breast Pump Request Form.

Pre-Service Authorization

The Alliance Medical Services department must review and approve select services before they are provided. Clinical review is to determine whether the service is clinically appropriate, performed in the appropriate setting, and is a covered benefit.

Clinical information is necessary for all services that require a medical necessity review. The requesting provider marks a decision timeframe on the authorization form based on the urgency of the requested service. To ensure a timely decision, make sure all supporting clinical information is included with the initial request. The preferred method for clinical review submission is via fax. If clinical review information is not received with the authorization request form, our Medical Services staff will fax a request for the information and/or call the provider to collect the necessary documentation.

Clinical information about the member includes:

  •     History of presenting problem
  •     Physical assessment
  •     Diagnostic results
  •     Photographs
  •     Consultations
  •     Previous and current treatment
  •     Member's response to treatment

Clinical information should be provided at least 5 days prior to the planned service date to ensure timely notification of coverage approval. The provider is responsible for obtaining authorization. Please provide an authorization reference number on all referrals and claims.

 

Determination turnaround times
 in accordance with appropriate contract/regulatory standards for all Alliance lines of business

Non-Urgent Requests

Within 5 calendar days of receipt

Urgent Requests

Within 72 calendar hours of receipt

Urgent Concurrent Decisions

Within 24 calendar hours of receipt

Post-Service Decisions

Considered only if it's due to member

eligibility issues or services were rendered

in an urgent situation.

Post-Service Authorizations

The Alliance accepts authorizations submitted after the date(s) of service(s) on a case by case basis. Generally, retrospective reviews are granted for instances in which Alliance member eligibility was not identified at time of service or care was rendered to prevent further harm to the member. To initiate the retrospective review process, please submit an Alliance Authorization Request (AAR) form and mark the request as “Retro”. The Alliance will review the request and issue a formal Notice of Action following the review.

Inpatient Review

The Alliance’s Inpatient Utilization Management nurses are assigned to follow members admitted for inpatient care, at specific acute care facilities, to promote collaboration with the facility's review staff and manage the member across the continuum of care. Our nurse reviewers assess both the care and services provided in the inpatient setting and the member's response to the care by applying MCG® guidelines. Together with the facility's staff, the TOC clinical staff coordinates the member's discharge needs.

All elective facility admissions require prior authorization review. Be sure to include documentation of medical necessity to facilitate the earliest possible turnaround time. The facility is responsible for ensuring authorization of the facility admission.

Requests for Medical Review Criteria

Providers may obtain a copy of any benefit provision or criteria we use to make our utilization management decisions by calling the Utilization Management Department at 510-747-4540 or 1-877-897-4388. Providers may request criteria for authorizations managed internally by the Alliance. Providers may contact our delegated partners directly for a copy of the criteria used in their utilization management decisions.

All utilization management determinations are made based on consistently applied criteria. The criteria are selected based on nationally recognized and evidence-based standards of practice for medical services and are applied on an individual needs basis. Primarily, the Alliance uses criteria from Medi-Cal and MCG Care Guidelines. If indicated, the Alliance may also conduct independent medical reviews.

Denials and Appeals

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

Written denial notification is sent to the requesting provider via fax and mailed to the member. 

The written denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline on which the denial decision was based and directions on how to obtain a copy of the reference. Providers may contact the Alliance’s Authorizations department to request a copy of the criteria used to make a decision about an authorization request.

It is also the Alliance’s policy to make an appropriate practitioner reviewer available to discuss any UM denial decision with the requesting provider by contacting the Alliance’s Authorizations department.

Providers can submit an appeal to the Alliance by contacting the Grievances & Appeals department.

Continuity of Care

 

The Alliance is committed to ensuring that our eligible members receive medically necessary services without interruption.
 
The Alliance has a continuity of care process for providers not contracted with the Alliance (also known as out-of-network). New Alliance members may continue to see their non-contracted physicians and utilize specific medical services, for up to12 months for their medical services after enrollment, as long as the following Continuity of Care guidelines are met. Separate continuity of care guidelines for exist for Medi-Cal and Group Care members:

Medi-Cal 
  • There is a demonstrated pre-existing relationship between the member and the physician during the 12 months prior to enrollment (member self-attestation does not qualify)
  • The physician is willing to accept the higher of the Alliance contract rates or Medi-Cal Fee For Service rates
  • There are no quality-of-care issues or a failure to meet federal or state requirements that would exclude the provider from the plan’s network.

Durable medical equipment, transportation, other ancillary services, and carved-out services are excluded from continuity of care protections. 

Group Care
  • There is a demonstrated pre-existing relationship between the member and the physician during the 12 months prior to enrollment (member self-attestation does not qualify)
  • The physician is willing to the higher of the Alliance contract rates or Medi-Cal FFS rates
  • There are no quality-of-care issues or a failure to meet federal or state requirements that would exclude the physician from the plan’s network
  • The member has one of the following medical conditions:
    • An acute condition
    • Serious chronic condition
    • Pregnancy
    • Terminal illness
    • Newborn child care between birth and age 36 months
    • An authorized covered service to be provided within 180 days of member’s effective date of enrollment


In addition to above continuity of care provisions, the Alliance provides additional access to care depending on the program:

 

Outpatient Mental Health Services  Continued access up to 12 months certain outpatient mental health services to members with mild to moderate impairment of mental, emotional, or behavioral functioning resulting from a mental health diagnosis.
Low Income Health Program (LIHP) Continued access up to 12 months to out-of-network LIHP providers  for former LIHP beneficiaries.
Covered California to Medi-Cal Transition Continued access to services covered by an active Prior Treatment Authorization for up to 60 days or until a new assessment is completed by a provider contracted with the Alliance. The new treatment plan must include an assessment of the services specified by the pre-transition active Prior Treatment Authorization.
Seniors and Persons with Disabilities Continued access to services covered by an active Prior Treatment Authorization for up to 60 days or until a new assessment is completed by a provider contracted with the Alliance. The new treatment plan must include an assessment of the services specified by the pre-transition active Prior Treatment Authorization.
Behavioral Health Treatment Continued access to out-of-network Behavioral Health Treatment providers for up to 12 months if the member has seen the provider at least twice during the 12 months prior to plan enrollment.


Members and providers can submit a Medical Exemption Request (MER) that allows for exemption from enrollment into the Alliance until the member’s medical condition has stabilized enough to allow the member to transfer to an Alliance provider of the same specialty without deleterious medical effects.  Only members transitioning from Medi-Cal Fee-for-Service can apply for this exemption.

Requesting Continuity of Care

Members may request continuity of care by calling our Member Services line directly at 1-877-932-2738 between 8 a.m. and 5 p.m., Monday - Friday. TTY for deaf or hearing impaired callers: 711 or 1-800-735-2929.

Providers can request continuity of care for their patients by submitting an Alliance Authorization Request (AAR) to the Utilization Management department and noting that the request is for continuity of care purposes.

The Alliance will be contacting members transitioning from Covered California to obtain a list of medical services previously covered through a Prior Treatment Authorization and granting an authorization for up 60 days from enrollment date. The Alliance must receive a request from either the member or provider should the member need services beyond the initial 60 days.

The Alliance will process each continuity of care request within the following time frames depending on the urgency:

  • Thirty calendar days from the request date for routine, non-urgent or non-emergent needs
  • Fifteen calendar days if the member’s medical condition requires more immediate attention, such as upcoming appointments
  • Three calendar days if there is a risk of harm to the member.

Members will be offered an in-network provider alternative should the Alliance and the out-of-network provider be unable to reach an agreement. Members will be referred or assigned to an in-network provider if he or she does not make a selection.

Members may change their provider to an in-network provider at any time even if a continuity of care relationship has been established.

UM Staffing and Disclaimers

The Alliance Medical Services department employs clinical reviewers who are qualified to make UM and authorization decisions. The Alliance ensures that UM and authorization decision-making is based only on appropriateness of care and service and existence of coverage.

The Alliance does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM and authorization decision makers do not encourage decisions that result in underutilization.