Prior authorization request form Form

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Important Reminder:
Long-Term Care Form Requirements and Updates

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have some important reminders that we would like to share with you.
The Alliance utilizes several forms to help ensure we appropriately authorize all medically necessary services for our Long-Term Care (LTC) members. Services include member room and board, specialty care, durable medical equipment (DME), hospice, bed holds, and leave of absence. We rely on our provider partner community to complete the required forms to help ensure timely authorizations.
We are now working to bring the Subacute and Intermittent Care Facilities for the Developmentally Disabled (ICF/DD) homes into our network effective Monday, January 1, 2024.
In an effort to remain compliant with the DHCS guidance for notification of admission/transfer and discharge within 24 hours and align with the new Transitional Care Services (TCS), we have enhanced the Alliance Long-Term Care (LTC) – Discharge Disposition Form. To ensure our members continue to receive high-quality care after being discharged from your facilities.
To streamline and improve our efficiency in processing our member’s authorizations timely, we made updates to the following forms: • Alliance Long-Term Care (LTC) Authorization Request Form (ARF) (for LTC/Subacute/ Hospice Room and Board)
• Alliance Long-Term Care (LTC) Authorization Request Form (ARF) (for Ancillary Services) • Alliance Long-Term Care (LTC) – Discharge Disposition Form Below is a summary of changes to the forms: Alliance LTC – ARF (for LTC/Subacute/Hospice Room and Board) • New format • New options for Section 4: Level of Care Requested
o Requested Start and End Date o Level of care options, including hospice • Enhanced Section 5: Admission Source/Referral Information Alliance LTC – ARF (for Ancillary Services) • New format • Enhanced Section 4: Rendering Provider/Facility Information o CoC information to assist with the Anthem/adult expansion/new carve-ins

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 www.alamedaalliance.org 2/2 LTCPRVDRLTC FORM UPDATE 11/2023 FAXED 12.8.2023 Alliance LTC – Discharge Disposition Form • New options for Section 2: Discharge Disposition • Added Date of Discharge field in Section 3: Discharging Facility Information • Added Section 4: High-Risk Conditions • Added Section 5: Discharge Barriers • Added Section 6: Follow-Up Appointment Information • New options for Section 8: Nursing Facility Offered Member Home and Community- Based Services (HCBS) Effective Monday, January 1, 2024, the new Alliance Long-Term Care (LTC) forms will be available on the Alliance website at www.alamedaalliance.org/providers/calaim/long-term-care. Please complete and fax these forms to the Alliance Long-Term Care (LTC) Department at 1.510.747.4191 for processing. Please Note: Please continue to fax authorization requests for short-term Skilled Nursing Facility (SNF) care (not LTC custodial) to the Alliance Inpatient Utilization Management (UM) Department at 1.855.891.7409. The fax should include a face sheet with an admission request and clinical documentation indicating the need for skilled services.
Thank you for your continued partnership and for providing high-quality care to our members and community.