Prior authorization request form Form

Questions? Please contact the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 Email: providerservices@alamedaalliance.org www.alamedaalliance.org LTCPRVDRREQ DOC NOTIF 07/2024 FAXED 07/30/2024 Important Reminder: Long-Term Care (LTC) Authorization Request Documentation Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have some important reminders that we would like to share with you. To help ensure our members receive timely access to care and to remain compliant with the California Department of Health Care Services (DHCS), we require certain documents to perform our medical necessity review. The Alliance process aligns with the DHCS Title 22 Manual of Criteria for Medi-Cal Authorization, Chapter 7, and the DHCS Leave of Absence, Bed Hold, and Room and Board policy. For initial and extension nursing facility and subacute facility requests, please provide the following: • Authorization Request Form (ARF) • MD order with the level of care: Custodial or Subacute (ventilator/non-ventilator) • Facesheet • Pre-Admission Screening and Resident Review (PASRR) • Documentation to support the level of care requested: Current Minimum Data Set (MDS) 3.0, Care Plans, and notes related to discharge planning • Proof of submission of the Medi-Cal Long-Term Care Facility Admission and Discharge Notification (MC 171) form • DHCS 6200 (subacute) *When transferring from an acute facility the MDS and MC 171 may not be available. For bed hold requests: • Physicians orders for both the transfer to acute and for the bed hold • Proof of return (e.g., nursing notes, census, facesheet with recent readmission date) • Discharge Form if the member did not return We appreciate your partnership in submitting requests in a timely manner. The Alliance Long Term Care (LTC) request forms are available on the Alliance website at www.alamedaalliance.org/providers/provider-forms. Please fax these completed forms to the Alliance (LTC) Department at 1.510.747.4191 for processing. Thank you for providing high-quality care to our members and community. Together, we are creating a safer and healthier community for all.