1/5 Prior Authorization (PA) Request Form – Home Health The Alameda Alliance for Health (Alliance) Prior Authorization Request Form – Home Health 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

1. Only type responses in all the fields below. Do not handwrite or stamp.
2. All fields marked with (*) are required.
3. 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):  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 an 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:

3/5 Section 4: Home Health Agency Provider 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)):  School (03)  Homeless Shelter (04)  Home (12)  Assisted Living Facility (13)  Skilled Nursing Facility (31)  Nursing Facility (32)  Custodial Care (33)  ICF/DD (54)  Other:
Section 5: 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 6: 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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Section 7: Diagnoses/Service Code(s)
At least one (1) diagnosis code is required. *ICD Code(s) Primary (Check only if yes) ICD Code(s) Primary (Check only if yes)

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 *Code CPT/ HCPCS Description Modifier 1 Modifier 2

Days Per Week

Work Weeks *Visits
(# Days/ Week x

of Weeks)

*Total Billable Units (Billable Units x Visits)

5/5 UMMCAL/D-SNP PRVDRPA REQ FORM_HH 10/2025 Section 8: Documentation Requirements Start of Care Requests Please include the following documentation when submitting this form: • Written physician’s order
• Supporting documentation of the member’s Home Health services
• Current completed OASIS/485 and frequency order(s)
• Date of last face-to-face encounter with treating physician (must be within 90 days prior to start of care)
• Clinical supporting documentation o Primary diagnosis and significant comorbidities and/or other diagnoses
o Current health status/prognosis
o Date of onset of the illness
o For requested Home Health nurse visits and units, indicate the specific skilled nursing need to support the request
o Therapeutic goals to be achieved by each discipline and the anticipated time for achievement of goals o A description of the member’s support system, including whether assistance is available from household members, homemakers, attendants, or others
Continuing Care Requests Please include the following documentation when submitting this form: • Written physician’s order for continuing Home Health services from the treating physician
• Frequency of order(s) • Date of last face-to-face encounter with treating physician if >60 days have elapsed since the last Home Health request.
• Clinical supporting documentation o Primary diagnosis and significant comorbidities and/or other diagnoses
o Current health status/prognosis
o Date of onset of the illness
o For requested Home Health nurse visits and units, indicate the specific skilled nursing need to support the request
o The extent to which Home Health Aides or skilled care has been previously provided, and benefits or improvements demonstrated by such care
o A description of the member’s support system, including whether assistance is available from household members, homemakers, attendants, or others
o Include a statement as to the member's progress toward achieving the therapeutic goals