Prior authorization request form Form

Questions? Please call the Alliance Pharmacy Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4541 www.alamedaalliance.org OPUM_ORTHOTIC AUTH UPDATE 12/2022; FAXED 12/8/2022 Important Update: Orthotic Codes that Require Authorization Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update we would like to share with you.
Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management and Claims processes to help ensure proper claim payment to our provider partners, and alignment of authorized services. To accomplish this goal, we are reviewing each benefit and we will be sending you updates, as the information is ready to share.
This communication provides an update on orthotic codes that require prior authorization (PA). This will affect claims with the date(s) of service starting Monday, January 9, 2023, and onward. Enclosed with this notice is a code-specific list of orthotic codes that shows which codes require PA. The list can be found on our website at www.alamedaalliance.org/ providers/authorizations. Please refer to our website for the most up-to-date information about codes or benefits that require authorization.
In addition to the codes, our claims system will also validate that claims received match the authorization when an authorization is required. The following items will be validated: • Member name • Provider NPI • CPT and HCPC coding • Date(s) of service are within the authorized range • Number of units and/or visits • Place of service matches the site of care submitted on the authorization request form This update has been validated based on current publishable/billable coding for 2022 and was confirmed to be covered by the California Department of Health Care Services (DHCS).
If you have any questions, please call the Alliance Provider Services Department at 1.510.747.4510. Thank you for your continued partnership and for providing high-quality care to our members and the community.

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Orthotics A5500 DM ONLY CSTM PREP SHOE MX DNS INSRT Alameda Alliance for Health or Delegate A5501 DM ONLY CSTM PREP SHOE MOLD PTS FT Alameda Alliance for Health or Delegate A5503 DM ONLY MOD SHOE/CSTM ROLLER/ROCKER Alameda Alliance for Health or Delegate A5504 DM ONLY MOD SHOE/CSTM W/WEDGE SHOE Alameda Alliance for Health or Delegate A5505 DM ONLY MOD SHOE/CSTM W/MT BAR SHOE Alameda Alliance for Health or Delegate A5506 DM ONLY MOD SHOE/CSTM OFF SET HEEL Alameda Alliance for Health or Delegate A5507 DM ONLY NOS MOD SHOE/CSTM MOLD SHOE Alameda Alliance for Health or Delegate A5512 FOR DIAB ONLY MX DNSITY INSRT PRFAB Alameda Alliance for Health or Delegate A5513 DIA ONLY MX DN INSRT CSTM MLD P F E Alameda Alliance for Health or Delegate A6504 COMPRS BRN GARMNT GLOV WRST CSTM Alameda Alliance for Health or Delegate A6508 COMPRS BRN GARMNT FT THI LEN CSTM Alameda Alliance for Health or Delegate A6545 GRD CMPRS WRP NONELST BK 30-50 MMHG Alameda Alliance for Health or Delegate A6549 GRADIENT COMP STOCKING/SLEEVE NOS Alameda Alliance for Health or Delegate K0672 ADD LOW EXT ORTHOSIS REPL EACH Alameda Alliance for Health or Delegate L2005 KAFO ANY MATL AUTO RLS ANK JNT CSTM Alameda Alliance for Health or Delegate L2006 KAF DVC ANY MATERIAL ADJ CUSTOM FAB Alameda Alliance for Health or Delegate L2232 ADD LOW EXT ORTHOS ROCKR BOTTM CSTM Alameda Alliance for Health or Delegate L2492 ADD KNEE LIFT LOOP DROP LOCK RING Alameda Alliance for Health or Delegate L3000 FT INSRT MOLD UCB TYPE BERKLY SHELL Alameda Alliance for Health or Delegate L3160 FOOT ADJUSTBL SHOE-STYLD PSTN DEVC Alameda Alliance for Health or Delegate S1040 CRANIAL REMOLD ORTHOT PED CUST FAB Alameda Alliance for Health or Delegate ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR ORTHOTICS Before services are provided, please check: Member Eligibility ▪ Medical Group ▪ Benefit Coverage ▪ Contracted Provider ▪ Medi-Cal Excluded Code Questions? Please call the Alliance Provider Services Department at 1.510.747.4510 Please Note: This list does not include all services. Page 1 of 1 OPUM_ORTHOTICS PROC CODES REQ PA 11/2022