Central California Alliance For Health

 

Form Library

Welcome to the Alliance Form Library. Listed below you will find a list of forms, along with a brief description of their intended use.



Care Based Incentives (CBI) Forms


2017 Care Based Incentive Forms

Provider 2017 Care Based Incentive Forms

PCPs must submit all Fee-for-Service Incentive forms within 21 business days from the date of service.


•  2017 Fee For Service (FFS) Forms


Forms for Specific Health Education Programs

Healthy Breathing for Life


• Asthma Action Plan (AAP) - PCPs may use the form to create an Asthma Action Plan for members ages 5-64 with a diagnosis of asthma. The AAP provides instruction and information on how to self-manage asthma daily, including taking medications appropriately, and how to recognize and handle worsening asthma. The PCP and member complete the AAP shortly after an asthma diagnosis, an asthma exacerbation, or with change in asthma severity classification or medication change. Review the AAP at each visit and make adjustments as needed to achieve asthma control. PCPs that complete and fax the AAP to the Alliance may be eligible for payment through our Care Based Incentive (CBI) program.


There are two versions of the AAP for your convenience. The fillable AAP allows you to pick medications from a drop down list and type in the member's information and your instructions to the member. The printable AAP allows you to print out the document and check the box that corresponds to the medication you have prescribed.


•  Fillable AAP in English or Spanish or Hmong.


•  Printable AAP in English or Spanish or Hmong.



Healthy Weight for Life


Initial Referral and 6-Month and 12-Month Follow Up Referral - PCPs must use the form to refer members to the Healthy Weight for Life program and report members' Body Mass Index (BMI) to the Alliance. This program is for members ages 2-18 with a BMI at or above the 85th percentile. PCPs that complete and fax these forms to the Alliance may be eligible for payment through our CBI program; however, PCPs will only receive reimbursement of subsequent HWL follow up referral forms for up to two years per linked member.


Please fax only the completed referral form to the Alliance, not the Rx form. Give the completed Rx form to the patient and keep a copy in the patient's file.


Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - English
Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - Spanish
Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - Hmong

Member 2017 Care Based Incentive Forms

The following CBI forms are intended for member use. Providers may view and download these forms if they receive questions from members.



Forms for Specific Health Education Programs

Healthy Moms And Healthy Babies (HMHB)


Early Prenatal Care Form - Providers may be asked to complete this form after their member's first prenatal visit. Members who have a prenatal visit within their first twelve weeks of pregnancy can complete and submit this form to the Alliance to receive a $25 gift card. Members can also qualify for the gift card if they are pregnant and get a prenatal visit within 42 days of becoming an Alliance member.

• Fillable Early Prenatal Care Form in English or Spanish or Hmong.
• Printable Early Prenatal Care Form in English or Spanish or Hmong.


Other Forms

Claims

Comments/Suggestions for the Claims Department – Providers can use this form to send comments or suggestions to the Alliance Claims Department.

Corrected Claim Form – Providers can use this form to submit corrected claims. The form must be filled out and the claim must be attached. Please do not staple the claim to the form as this delays processing time.

EDI Trading Partner Agreement – All Transaction Types – This application is used by providers in order to enroll in various EDI transactions, such as 837 Electronic Claims Submission, 835 Electronic Remittance Advice, and others.

Interested in Electronic Claims Submission? – This form begins the electronic claims submission process.

Reimbursement Rates Form – This form is used by providers to request reimbursement rate information from the Alliance.


Finance

Credit Balance Report – This form needs to be filled out quarterly and sent to the Alliance.

Identification of an Overpayment – This form can be used to communicate an overpayment to the Alliance.

OHC Referral Form – This form needs to be filled out for a member's Other Health Coverage.

EFT/ACH Authorization – Complete this form to receive electronic payments via Electronic Fund Transfer/Automated Clearing House.

EFT/ACH Authorization Form Instructions – This document provides instructions on how to complete the Electronic Fund Transfer/Automated Clearing House Authorization Form.


Grievance

• Member Complaint Packets – These files can be printed out and handed to members who are interested in filing a complaint to the Alliance's Grievance Coordinator.
   – Member Complaint Packet in English
   – Member Complaint Packet in Spanish
   – Member Complaint Packet in Hmong

Need Help with Your HMO? (English and Spanish) – Flyers from California Department of Managed Health Care describing how members can get help regarding their health plan.


Health Program Forms (non-CBI)

Tobacco Cessation Support (TCS) Program


The TCS program offers many ways to help members quit smoking. Members are referred to the convenient, toll-free California Smokers' Helpline at 1-800-NO-BUTTS (1-800-662-8887), which provides free cessation counseling over the phone for anyone in California. We may also be able to help members enroll in an approved smoking cessation class. The provider is required to complete the TCS application.

  •  TCS Program Application, including eligibility and referral information.



Weight Watchers Support (WWS) Program


The WWS program is a weight management program that is not an Alliance benefit or a Medi-Cal benefit. In order to join the WWS program, members' primary insurance plan must be the Alliance, and members must meet referral criteria provided by their PCP, and the WWS application must be completed by the provider.

  •  WWS Program Application, including eligibility and referral information.



Comprehensive Perinatal Services Program (CPSP)


Per Title 22, Section 51348, contracted providers must perform a comprehensive risk assessment for all pregnant members that is comparable to the American Congress of Obstetricians and Gynecologists (ACOG) and CPSP standards. The forms below can be used during an initial prenatal visit, once each trimester thereafter, and at postpartum visits.

  •  Initial Combined Assessment
  •  Initial Combined Assessment Instructions
  •  Risk Strength Summary
  •  CPSP List of Billing Codes


Health Services

Advance Directives Form, English or Spanish – This free advance directives form is easy for patients to read and understand.

Attestation Regarding Extended Office Hours - The Alliance provides an incentive for qualifying Primary Care Providers who offer their linked members access to primary care services outside of standard business hours. In order to be eligible for this incentive, providers must complete the Attestation Form below and fax it to their Provider Services Representative at (831) 430-5857.

Authorization Inquiry Form – This form is used by providers to check if a CPT code(s) requires Prior Authorization.

Authorization Status Request – Providers can use this form to check the status of an authorization request.

Treatment Authorization Request – Providers can use this form for outpatient services, out-of-area authorized referrals, and durable medical equipment requests.

Request for Extension of Stay in Hospital – Providers can use this form for an extension of inpatient hospital stays.

Long Term Care Treatment Authorization Request – Providers can use this form to request authorization for long term care.

Community Based Adult Services (CBAS) Inquiry Form – Providers may submit an inquiry for services by completing a CBAS inquiry form.

Consent for Sterilization or Hysterectomy Sample Form – This is a sample form to obtain consent for sterilization or a hysterectomy. Offices can feel free to duplicate this form and add their letterhead.

Clinical Summary of Patient’s Nutrition Status – Providers can use this form to assist with providing documentation to prove medical necessity of oral or enteral nutrition formulas. Submit this form along with a prescription, Treatment Authorization Request and any other pertinent clinical documentation when requesting authorization through the Alliance Pharmacy. Although submitting the form is not mandatory to process authorization requests, the form is available to streamline the review process and to ensure providers submit all the information necessary to justify medical necessity.

• Medi-Cal Provider Preventable Conditions (PPC) Reporting – Providers are required to report PPCs to the Department of Health Care Services (DHCS) Audits and Investigations Division within 5 working days of discovery, via the DHCS online reporting portal. A copy must be emailed to the Alliance Quality Improvement department at PPC@ccah-alliance.org.

• Medication Management Agreement (MMA) - PCPs may use this form to create a Medication Management Agreement for their members.
  •  MMA in English, Spanish, or Hmong.

• Physician Orders for Life-Sustaining Treatment (POLST) - This form is designed to ensure that conversations on end-of-life planning occur with seriously ill patients, allowing them to choose the treatments they want and helping ensure that their wishes are honored by medical providers.
  •  POLST in English
  •  POLST in Spanish
  •  POLST in Hmong
  •  POLST forms in additional languages

Prescription Drug Prior Authorization Request Form – For Healthy Kids, IHSS and Medi-Cal Access Program members, prior authorization requests for medications must be submitted on this prior authorization form.

Provider Change Request (PCR) – This form is used to make simple changes to an existing Prior Authorization.

Request for Administrative Member Classification – This form is used by providers requesting that an Alliance member be made an administrative member.

Staying Healthy Assessment Order Form – Use to order bulk quantities of the SHA forms and patient handouts in English, Spanish, and Hmong.
To print Staying Healthy Assessment forms and handouts directly, please visit the Staying Healthy Assessment page of the Alliance website for PDF versions in English, Spanish, and Hmong. Additional languages may be available from the Department of Health Care Services SHA website.

Please note: Remember to use the SHA during the Initial Health Assessment as well as subsequent well exams. Members who schedule an Initial Health Assessment and see their PCP within three months of enrollment with the Alliance as a Medi-Cal member, are eligible for a monthly raffle for a $50.00 gift card. This incentive is intended to raise awareness of the importance of developing a good relationship with the PCP, and to improve compliance rates for timely Initial Health Assessments.

• Synagis Recommendations and Medical Necessity Form – These are the yearly Synagis memos that discuss criteria for Synagis and how to obtain prior authorization. For providers who wish to administer Synagis in their office, the Statement of Medical Necessity form is required to be submitted along with the prior authorization request.

   – Instructions for Santa Cruz County and Monterey County
   – Instructions for Merced County


Provider Services

Certification Regarding Debarment Suspension, Ineligibility and Voluntary Exclusion – Form sent to the Alliance with signed Services Agreement.

Certification Regarding Lobbying - Exhibit D(F) Att 1 and 2 – If payments to provider under the Services Agreement are $100,000 or more, provider shall submit the "Certification Regarding Lobbying" to the Alliance.

Locum Tenens Notification Form – Locum tenens are providers who temporarily take the place of, or cover, for another provider. All locum tenens who render services to the Alliance members must be disclosed to the Alliance's Provider Services Credentialing staff before providing care to Alliance members.

Member Appointment No-Show Notification – This form is used to inform Member Services that an Alliance member did not keep a scheduled appointment.

Patient Complaint / Grievance Tracking Log – Form that Physicians/Providers can use to track patient requests for Complaint / Grievance Forms.

Provider Applications – If you are interested in becoming an Alliance provider, visit our Joining our Network page.

Provider Dispute Form – This form is used by provider to file a dispute with the Alliance.

Provider Information Change Form – This form is used to update contact and practice information. Information includes provider address, phone number, contact information, payment address, and tax ID number.

Referral Consultation Request Form (sample only) – This form is for the use of a Primary Care Provider when referring their linked member for specialty care. Referrals to out-of-service-area providers must be approved by the Alliance by submitting a Treatment Authorization Request Form.
   – Instructions for completing the Referral Consultation Request
      Form

Reimbursement Rates Form – This form is used by providers to request reimbursement rate information from the Alliance.

• Request for Member Reassignment – Forms, procedures, and member notices to be used when requesting member reassignment.
   – Request for Member Reassignment Form
   – Request for Member Reassignment Procedure

• Member Notice Letters –
   – English
   – Spanish
   – Hmong







 

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