Post Acute Authorization Form Form

1/5

Authorization Request Form (Post Acute Care)

The Alameda Alliance for Health (Alliance) Long-Term Care (LTC) Department – Authorization Request Form (ARF) (Post Acute Care) is confidential. Please use this form to request authorization for Alliance Medi-Cal and Alameda Alliance Wellness (HMO D-SNP) members. 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. Please print clearly or type in all of the fields below.
2. All fields marked with (*) are required.
3. Include the following attachments: a. Verification of Alliance eligibility b. Physician order with physician signature c. Documentation to support the level of care requested (i.e., Minimum Data Set (MDS) 3.0 [LTC], PASRR, notes related to discharge planning, etc.)
4. Print and fax the completed form: • For Skilled Nursing Facility (SNF)/Short-Term Subacute requests, please fax the completed form to the Alliance Inpatient Team at 1.855.313.6306. • For Long-Term Care (LTC)/Long-Term Subacute requests, please fax the completed form to the Alliance LTC Department at 1.510.747.4191.
   Please Note: Incomplete forms may be delayed or declined and returned to the referral source. Authorization does not guarantee payment. The Alliance reserves the right to request additional documentation as needed to make a determination. If you have any questions, please call the Alliance LTC Department at 1.510.747.4516.

2/5  Clinicals are required to be submitted with this form. Please check this box to certify 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 (TIN): Office Contact Person Full Name: Phone Number: Fax Number: Email: Section 2: Type of Request Please select only one (1):  Retro – Request for members who have already been admitted. 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.  Initial Authorization (LTC)  Reauthorization (LTC)  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 a 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.  Hospital D/C to LTC  Hospital D/C to Skilled  Ongoing Skilled Concurrent Review  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:

3/5 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: If yes, please complete Section 4: Medicare/Benefit Status. Section 4: Medicare/Benefit Status Medicare Status (please select all that apply):  A  B  C  D Benefit Status (please select only one (1)):  Benefits exhausted: • Date Medicare Benefits Exhausted (MM/DD/YYYY): • Dual Eligible Special Needs Plan (D-SNP) • Please attach the Notice of Medicare Non-Coverage (NOMNC)  Benefits NOT exhausted: • Number of Medicare Days Available: • Other Dual Eligible Special Needs Plan (D-SNP) Section 5: Servicing Facility Information Facility Name: Address: City: State: Zip Code: NPI Number: Tax ID Number (TIN): Phone Number: *Fax Number: Facility Contact Person Full Name:

4/5 Section 6: Admission Source/Referral Information Please select only one (1):  Acute hospital  Board and care/assisted living facility  Emergency Room  Home  LTC custodial  Physician referral  SNF  Street  Transfer from hospital  Transfer from residential facility  Transfer from another healthcare facility Date of LTC Placement Referral (MM/DD/YYYY): Reason for LTC/SNF Placement:
Section 7: 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)):  Continuity of Care (CoC)  In-network provider not accepting new patients  In-network provider type, specialty, or covered service not available  Patient request  Specialized procedure/area of expertise  Timely access to provider  Other:
Section 8: Level of Care Requested Please select only one (1) level of care per request form. Requested Start Date: Requested End Date: Diagnosis: *Diagnosis (ICD) Code(s): Skilled Nursing  Skilled 1  Skilled 2  Skilled 3  Skilled 4  Sub-acute (non-vent) LOS Day 0-30  Sub-acute (vent) LOS Day 0-30 Please select only one (1):

5/5 LTCMCAL D-SNP PRVDRARF_POST ACUTE CARE 11/2025 Section 8: Level of Care Requested (cont.) Please select only one (1) level of care per request form. Bed Hold (maximum of seven (7) days) (if selected, please include MD orders for transfer and bed hold)  LTC – Bed hold (maximum of seven (7) days)  SNF – Bed hold (maximum of seven (7) days) Leave of Absence (maximum of 18 days per calendar year)  LTC – Leave of absence  SNF – Leave of absence Long-Term Care  NF-A (custodial)  NF-B (custodial)  Sub-acute (non-vent) LOS Day >30  Sub-acute (vent) LOS Day >30
Section 9: Member’s General Condition Please select all that apply:  Ambulatory  Ambulatory with assistance  Confined to bed  Confined to wheelchair  Incontinent of bowel and bladder  Maximum assistance with all activities of daily living (ADLs) Section 10: Additional Comments Additional Comments: