Prior Authorization Form Form
Please answer all questions to determine coverage (0 of 1)
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Prior Authorization (PA) Request Form
The Alameda Alliance for Health (Alliance) Prior Authorization Request Form is confidential.
Please use this form to request prior authorization for all Alliance lines of business (i.e., Medi-Cal,
Group Care, and Alameda Alliance Wellness (HMO D-SNP)). Authorizations are based on medical
necessity and covered services. 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. The Alliance member must be eligible on the date of service, and the
procedure must be a covered benefit. The remaining balance may not be billed to the patient.
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
- Only type responses in all the fields below. Do not handwrite or stamp.
- All fields marked with (*) are required.
Print and fax the completed typed form to the Alliance Utilization Management (UM) Department at 1.855.891.7174. Please Note: Handwritten or incomplete forms may be delayed. If you have any questions, please call the Alliance UM Department at 1.510.747.4540.
*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 Facility Name:
*Last Name:
First Name:*Address:
City:
State:
*Zip Code:NPI Number:
Tax ID Number:Office Contact Person Full Name:
Phone Number:
Fax Number:Email:
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Section 2: Type of Request
Please select only one (1):
Medication (Physician-Administered Drug, PAD) – Please see below for the time that
the Alliance has to process medication requests:
Medi-Cal
Group Care
Alameda Alliance
Wellness (HMO D-SNP)
Routine (Approval based
on Alliance clinical review)
24 hours
7 calendar
days
72 hours
Urgent (Inappropriate
use will be monitored)
24 hours
72 hours
24 hours
Retro – Granted for eligibility issues or urgent care. Requests must be within 90 days of
the date of service. Processing time is up to 30 calendar days from receipt.
Routine – Based on Alliance clinical review. The Alliance has up to seven (7) calendar
days to process routine requests for all lines of business.
Standing Referral – The Alliance has up to three (3) business days to process requests
for standing referrals.
Urgent – Defined as a request for medical services that needs prompt decision because a
member’s condition presents as an imminent and serious threat to the member’s health, such
as potential loss of life, limb, or a major bodily function. Inappropriate use will be monitored.
The Alliance has up to 72 hours to process urgent requests for all lines of business.
Authorization Change Request – Request for existing authorized services. Please enter
the Alliance authorization number and the member information below. Use a separate
sheet to specify your changes or to attach additional supporting documentation.
If Authorization Change Request, please provide the Alliance Authorization Number:
Section 3: Member Information
For newborn services, provide the mother's 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:
Other Insurance (please select all that apply, and include the name of your insurance):
Commercial:
Medi-Cal:
Medicare:
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Section 4: Requested Service
Please select one (1) service from either Outpatient and Elective Services or Behavioral
Health Services. Do not select from both categories.
Outpatient and Elective Services
Please select only one (1):
Acupuncture
Chiropractic
Clinical Trials
Community Based Adult
Services (CBAS)
Dialysis (out of network)
Durable Medical Equipment
(DME)/Supplies
Gender Affirming Care
Genetic Testing
Inpatient Elective Surgery
Laboratory/Pathology
Outpatient (OP) Surgery
Physical Therapy/
Occupational Therapy/
Speech Therapy
Physician Administered
Drug (PAD)
Podiatry
Private Duty Nursing (PDN)
Prosthetics
Radiology
Specialty Referral
Stanford Oncology
Tertiary/ Quaternary
Care (T/Q)
Transgender Services
Transplant Evaluation
Transplant Surgery
Behavioral Health Services
Please select only one (1):
Applied Behavioral Analysis (ABA)/ Behavioral Health Therapy (BHT)
Behavioral Health (Mental Health/ Substance Use Disorders)
Section 6: Rendering/Servicing Provider Information
Last Name:
First Name:
Specialty:
Address:
City:
State:
Zip Code:
NPI Number:
Tax ID Number:
Phone Number:
Fax Number:
Starting Service Date:
Ending Service Date (if known):
*Place of Service (please select only one (1)):
Durable Medical Equipment (DME)
Office (11)
Home (12)
Inpatient Hospital (21)
Outpatient Hospital (22)
Ambulatory Surgical Center (24)
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Section 7: Rendering/Servicing Facility Information (if applicable)
Facility Name:
Department:
Address:
City:
State:
Zip Code:
NPI Number:
Tax ID Number:
Phone Number:
Fax Number:
Section 8: Out-of-Network Information
Is the service being requested out-of-network: Yes No
If Yes, provide the reason for out-of-network facility/provider (please select only one (1)):
In-network provider not accepting new
patients
In-network provider not available
Patient request
Specialized procedure/Area of expertise
Timely access to provider
Other:
Section 9: Discharge Planning Information
Is the service needed for discharge planning: Yes No
If Yes, what is the discharge date (MM/DD/YYYY)?
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UMMCAL/D-SNP PRVDRPA REQ FORM 10/2025
Section 10: Diagnoses/Service Codes
At least one (1) diagnosis code is required.
*ICD Code(s)
Primary
(Check
only if yes)
ICD Code(s)
Primary
(Check only
if yes)
Code CPT/HCPCS Description Modifier 1 Modifier 2 Quantity Unit Type Total Billable Units
Walk through this policy with us
Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.