Alameda Alliance For HealthCommercial Clinical Policy

Community Supports Authorization Form Form

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Community Supports Authorization Form

Indications

(1) Please print clearly or type in all the fields below. 2. Attach a clinical summary and/or supporting documentation (i.e., clinic notes, hospital discharge summary, etc.) for the requested Community Support. 3. Please fax or email the completed form to the Alliance Community Supports Department at 1.510.995.3726 or CSDept@alamedaalliance.org. Please Note: Handwritten or incomplete forms may be delayed. Forms submitted without supporting information may also be delayed. If you have any questions, please call the Alliance Community Supports Department at 1.510.747.4545.  Clinicals are required to be submitted with this form. Please check this box to certify that clinicals have been attached. Section 1: Requesting Provider Information Last Name: First Name: Address: City: State: Zip Code: NPI Number: Tax ID Number (TIN): Office Contact Person Full Name: Phone Number: Fax Number: Email: Date of Request: Service Start Date: Service End Date: 2/4 Section 2: Member Information Last Name: First Name: Date Of Birth (MM/DD/YYYY): Alliance Member ID Number: Client Index Number (CIN): Medicare Beneficiary Identifier (MBI): Address: City: State: Zip Code: Phone Number:  Home  Cell Primary Diagnosis (including ICD-10 code(s)): Is the member currently linked to a case management (ECM/CM) team? Yes  No? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



1/4 Community Supports – Authorization Request Form

The Alameda Alliance for Health (Alliance) Community Supports Authorization Request Form is confidential. Please use this form to request authorization for Alliance Medi-Cal and Alameda Alliance Wellness (HMO D-SNP) members. Authorizations are based on the appropriateness of the service being requested. Authorizations are contingent upon the member’s eligibility and are not a guarantee of payment. The provider is responsible for verifying the member’s eligibility on the date of service.
If you are interested in joining the Alliance network, please call the Alliance Provider Services Department at 1.510.747.4510. The easiest and fastest way to verify eligibility is through the Alliance Provider Portal. To log in or create an account, visit the Alliance website at www.alamedaalliance.org and click on the Provider Portal button in the top right corner, and you will be redirected to our Provider Portal. If you are creating an account, please allow two (2) business days for the Alliance Provider Service Department to review and respond.
INSTRUCTIONS

  1. Please print clearly or type in all the fields below.
  2. Attach a clinical summary and/or supporting documentation (i.e., clinic notes, hospital discharge summary, etc.) for the requested Community Support.

  3. Please fax or email the completed form to the Alliance Community Supports Department at 1.510.995.3726 or CSDept@alamedaalliance.org. Please Note: Handwritten or incomplete forms may be delayed. Forms submitted without supporting information may also be delayed. If you have any questions, please call the Alliance Community Supports Department at 1.510.747.4545.

     Clinicals are required to be submitted with this form. Please check this box to certify that clinicals have been attached. Section 1: Requesting Provider Information Last Name:
    First Name:

    Address:

    City:
    State:
    Zip Code:

    NPI Number:
    Tax ID Number (TIN):

    Office Contact Person Full Name:

    Phone Number:
    Fax Number:

    Email:

    Date of Request:

    Service Start Date:
    Service End Date:

2/4 Section 2: Member Information Last Name:
First Name:
Date Of Birth (MM/DD/YYYY):
Alliance Member ID Number:
Client Index Number (CIN):
Medicare Beneficiary Identifier (MBI):
Address:
City:
State:
Zip Code:
Phone Number:
 Home  Cell Primary Diagnosis (including ICD-10 code(s)):
Is the member currently linked to a case management (ECM/CM) team? Yes  No Case Manager/ECM Name:
Case Manager/ECM Phone Number:
Section 3: Servicing Provider Information Last Name:
First Name: Address:
City:
State:
Zip Code: NPI Number:
Tax ID Number (TIN): Phone Number: Fax Number:
Email:
Section 4: Requested Service(s) Type of Request Please select only one (1):  Initial Request  Extension Request Previous Authorization Number:

3/4 Section 4: Requested Service(s) (cont.) Please select all that apply: Assisted Living Facility (ALF) Transitions  T2038 (U4)  H2022 (U5) Asthma Remediation  S5165 Units/Description: Community or Home Transition Services  T2308 (U5) Environmental Accessibility Adaptations (Home Modifications)  S5165 (U6)  S5161 (U6) – PERs Housing Deposit  H0044 (U2) Housing Tenancy and Sustaining Services  T2040 (U6) – Financial management  T2041 (U6) – Brokerage support Housing Transition Navigation Services  H0043 (U6)  H2016 (U6) Medically Tailored Meals (MTM)/Medically Supportive Food (MSF) Meal Frequency Request  S5170 (U6) – One (1) meal per day
 S5170 (U6) – Two (2) meals per day Medically Supportive Food  S9470 (U6) – One (1) grocery box per week  S9977 (U6) – Nutritional Counseling (included when paired with direct food assistance) Personal Care and Homemaker Services (PCHS)  T1019 (U6) Hours:
 S5130 (U6) – Members older than 18 years of age Hours:

4/4 CSMCAL DSNPPRVDR_AUTH REQ FORM 11/2025 Section 4: Requested Service(s) (cont.) Recuperative Care (Medical Respite)  T2033 (U6) Respite Services  S9125 (U6) – In the Home  H0045 (U6) – Not in Home  S5151 (U6) – Unskilled Transitional Rent  H0043 (U2) – Interim
 H0044 (U6) – Permanent Section 5: Patient’s Medical Necessity Please describe and attach all supporting documentation to the form:

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