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_AC, ALGY, BLOOD PLASMA, SLEEP STUDY, EEG AUTH UPDATE 07/2021 Important Update: Acupuncture, Allergy, Blood Plasma, Sleep Study and Electroencephalogram (EEG) Codes that Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management (UM) 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 Acupuncture, Allergy, Blood Plasma, Sleep Study and Electroencephalogram (EEG) codes that require prior authorization (PA).
This will affect claims with date(s) of service starting, Monday, August 2, 2021, and onward. Enclosed with this notice is a code-specific list for Acupuncture, Allergy, Blood Plasma, Sleep Study and EEG codes that shows which codes require PA. The code list as well as the most current information about codes or benefits that require PA can be found on our website at www.alamedaalliance.org/providers/authorizations.
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 is within the authorized range • Number of units and/or visits
• Place of service matches site of care submitted on the authorization request form
This update has been validated based on current and published billable coding for 2021 and was confirmed to be covered by the California Department of Health Care Services (DHCS).
If you have 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 Acupuncture 97810 ACUPUNCT W/O STIMUL 15 MIN The Alliance or Delegate 97811 ACUPUNCT W/O STIMUL ADDL 15M The Alliance or Delegate 97813 ACUPUNCT W/STIMUL 15 MIN The Alliance or Delegate 97814 ACUPUNCT W/STIMUL ADDL 15M The Alliance or Delegate Allergy Services 86003 ALLG SPEC IGE CRUDE XTRC EA The Alliance or Delegate 86008 ALLG SPEC IGE RECOMB EA The Alliance or Delegate 95115 IMMUNOTHERAPY ONE INJECTION The Alliance or Delegate 95117 IMMUNOTHERAPY INJECTIONS The Alliance or Delegate Blood Products (infusion of blood (A, B, O),  plasma,  platelets, cryoinfusion)  P9010 BLOOD FOR TRANSFUSION PER UNIT The Alliance or Delegate For blood derivatives ‐ see the infusion PA coding list P9011 BLOOD SPLIT UNIT The Alliance or Delegate P9012 CRYOPRECIPITATE EACH UNIT The Alliance or Delegate P9016 RBCS LEUKOCYTES REDUCED EACH UNIT The Alliance or Delegate P9017 FFP FRZN WITHIN 8 HRS CLCT EA UNIT The Alliance or Delegate P9019 PLATELETS EACH UNIT The Alliance or Delegate P9020 PLATELET RICH PLASMA EACH UNIT The Alliance or Delegate P9021 RED BLOOD CELLS EACH UNIT The Alliance or Delegate P9022 RED BLOOD CELLS WASHED EACH UNIT The Alliance or Delegate P9023 PLASMA POOL MX DONOR FROZEN EA UNIT The Alliance or Delegate P9031 PLATLTS LEUKOCYTES REDUCED EA UNIT The Alliance or Delegate P9032 PLATELETS IRRADIATED EACH UNIT The Alliance or Delegate P9033 PLATLTS LEUKOCYTES RDUC IRRADATD EA The Alliance or Delegate P9034 PLATELETS PHERESIS EACH UNIT The Alliance or Delegate P9035 PLATLTS PHERES LEUKOCYTES RDUC EA U The Alliance or Delegate P9036 PLATELETS PHERESIS IRRADATD EA UNIT The Alliance or Delegate P9037 PLATLT PHERES LEUKOCYT RDUC IRRADTD The Alliance or Delegate ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR  ACUPUNCTURE, ALLERGY, BLOOD PLASMA, SLEEP STUDY, and ELECTROENCEPHALOGRAM (EEG)  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 3

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Blood Products (infusion of blood (A, B, O),  plasma,  platelets, cryoinfusion) (cont.) P9038 RBCS IRRADIATED EACH UNIT The Alliance or Delegate P9039 RBCS DEGLYCEROLIZED EACH UNIT The Alliance or Delegate P9040 RBCS LEUKOCYTES RDUC IRRADATD EA U The Alliance or Delegate P9041 INFUSION ALBUMIN HUMAN 5% 50 ML The Alliance or Delegate P9043 INFUS PLSMA PROT FRAC HUMN 5% 50 ML The Alliance or Delegate P9044 PLSMA CRYOPRECIPITATE RDUC EA UNIT The Alliance or Delegate P9045 INFUSION ALBUMIN HUMAN 5% 250 ML The Alliance or Delegate P9046 INFUSION ALBUMIN HUMAN 25% 20 ML The Alliance or Delegate P9047 INFUSION ALBUMIN HUMAN 25% 50 ML The Alliance or Delegate P9048 INFUS PLSMA PROT FRAC HU 5% 250 ML The Alliance or Delegate P9050 GRANULOCYTES PHERESIS EACH UNIT The Alliance or Delegate P9051 WHOLE BLD/RBCS LEUKOCYTES RDUC CMV‐ The Alliance or Delegate P9052 PLT HLA‐MATCHD LEUKOCYTES RDUC EACH The Alliance or Delegate P9053 PLT PHERES LEUKOCYT RDUC CMV‐NEG EA The Alliance or Delegate P9054 WHOLE BLD/RBCS LEUKOCYTES RDUC FRZN The Alliance or Delegate P9055 PLT LEUKOCYT RDUC CMV‐NEG APH/PHERS The Alliance or Delegate P9056 WHOLE BLD LEUKOCYTES RDUC IRRADATD The Alliance or Delegate P9057 RBCS FRZN/DEGLYCEROLIZED/WASHED LEU The Alliance or Delegate P9058 RBCS LEUKOCYTES RDUC CMV‐NEG IRRADA The Alliance or Delegate P9059 FRESH FRZN PLAS BETWN 8‐24 HR CLCT The Alliance or Delegate P9060 FRESH FRZN PLSMA DONR RETESTED EA U The Alliance or Delegate P9073 PLATELETS PHERESIS PATHOGEN‐REDUCED The Alliance or Delegate P9100 PATHOGEN TEST FOR PLATELETS The Alliance or Delegate 36440 BL PUSH TRANSFUSE 2 YR/< The Alliance or Delegate 36450 BL EXCHANGE/TRANSFUSE NB The Alliance or Delegate 36455 BL EXCHANGE/TRANSFUSE NON‐NB The Alliance or Delegate 36456 PRTL EXCHANGE TRANSFUSE NB The Alliance or Delegate 36460 TRANSFUSION SERVICE FETAL The Alliance or Delegate 86850 RBC ANTIBODY SCREEN The Alliance or Delegate 86860 RBC ANTIBODY ELUTION The Alliance or Delegate 86870 RBC ANTIBODY IDENTIFICATION The Alliance or Delegate 86927 PLASMA FRESH FROZEN The Alliance or Delegate 86945 BLOOD PRODUCT/IRRADIATION The Alliance or Delegate 86999 TRANSFUSION PROCEDURE The Alliance or Delegate Please note: This list does not include all services. Page 2 of 3

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO EEG (Electroencephalogram) 95711 VEEG 2‐12 HR UNMONITORED The Alliance or Delegate 95712 VEEG 2‐12 HR INTMT MNTR The Alliance or Delegate 95713 VEEG 2‐12 HR CONT MNTR The Alliance or Delegate 95714 VEEG EA 12‐26 HR UNMNTR The Alliance or Delegate 95715 VEEG EA 12‐26HR INTMT MNTR The Alliance or Delegate 95716 VEEG EA 12‐26HR CONT MNTR The Alliance or Delegate Sleep Study  95782 POS AIRWAY PRESSURE CPAP The Alliance or Delegate 95783 POLYSOM <6 YRS 4/> PARAMTRS The Alliance or Delegate 95805 POLYSOM 6 YRS CPAP/BILVL The Alliance or Delegate 95807 MULTIPLE SLEEP LATENCY TEST The Alliance or Delegate 95808 SLEEP STUDY ATTENDED The Alliance or Delegate 95810 POLYSOM ANY AGE 1‐3 PARAM The Alliance or Delegate 95811 POLYSOM 6/> YRS 4/> PARAM The Alliance or Delegate 95822 POLYSOM 6/>YRS CPAP 4/> PARM The Alliance or Delegate 94660 EEG COMA OR SLEEP ONLY The Alliance or Delegate Please note: This list does not include all services. Page 3 of 3

Questions? Please call the Alliance Provider Services Department
or you may contact your Provider Representative directly. Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 www.alamedaalliance.org PS_E-SUB PA REQ 07/2020 FAXED/POSTED: MM/DD/2020 Important Reminder: For Faster Processing, Please Submit Prior Authorization (PA) Requests Electronically

Through the Online Alliance Provider Portal

At Alameda Alliance for Health (Alliance), we value our dedicated provider partner community. We would like to share this important reminder with you about using our provider portal to assist with operational efficiency as we continue to address the impacts of COVID-19.
Effective immediately, we continue to strongly advise our providers to submit Prior Authorization (PA) Requests electronically, through the Alliance Provider Portal. This will help you receive a decision sooner. A number of our operations have been transitioned to be performed remotely and we can process PA forms that are submitted electronically more quickly, than PA forms that are submitted by fax.
How do I submit a PA through the Alliance Provider Portal?
Login to the Alliance Provider Portal using Google Chrome and follow these steps: Step 1: Click on “Submit Authorizations” under the Authorization quick link. Step 2: Click on “select a form” and choose the appropriate authorization type from the drop-down menu:
• Inpatient Authorization (elective procedures only) • Outpatient Authorization Step 3: Enter all required fields as directed in this section. Step 4: Attach medical records to avoid further delay of a review or possible denial of services. Step 5: Click “submit request” once you are ready to submit. How do I create an Alliance Provider Portal account?

1. Visit www.alamedaalliance.org.
2. Click “Provider Portal” from the website homepage.
3. Click “Create a new account”. Please Note: • This applies to outpatient services and elective procedures. ER admissions cannot be submitted through the Alliance Provider Portal. • All required fields, as indicated, must be completed. • Please double check that the CPT and DX codes are valid and/or Medi-Cal or Group Care covered codes, as appropriate, for the care or service that is being requested. • Please attach all required medical record documentation to the request to help prevent any delays with processing. • You will receive a reference number to show that the PA request was successfully submitted through the provider portal. Please note that this is not the PA number itself.
   Thank you for your ongoing partnership and for providing high-quality care to our members and community. Together, we are creating a safer and healthier community for all.