Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care Instructions
This form contains 166 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Commercial Insurance | ||
| Commercial Insurance Name | Text |
Enter the name of your commercial insurance provider.
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| Commercial | Checkbox |
Check this box if the member has commercial insurance.
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| General | ||
| Certify Clinicals Attached | Checkbox |
Check this box to certify that clinicals have been attached to this form.
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| Facility Name | Text |
Enter the full name of the facility.
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| Last Name | Text |
Enter the last name of the requesting provider.
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| First Name | Text |
Enter the first name of the requesting provider.
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| Address | Text |
Enter the street address of the facility or requesting provider.
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| City | Text |
Enter the city of the facility or requesting provider.
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| State | Text |
Enter the state of the facility or requesting provider.
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| Zip Code | Text |
Enter the zip code of the facility or requesting provider.
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| NPI Number | Number |
Enter the National Provider Identifier (NPI) number.
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| Tax ID Number | Number |
Enter the Tax Identification Number (TIN).
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| Office Contact Person Full Name | Text |
Enter the full name of the office contact person.
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| Phone Number | Text |
Enter the phone number of the requesting provider or facility.
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| Fax Number | Text |
Enter the fax number of the requesting provider or facility.
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| Text |
Enter the email address of the requesting provider or facility.
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| Last Name | Text |
Enter the last name of the rendering or servicing provider.
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| First Name | Text |
Enter the first name of the rendering or servicing provider.
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| Specialty | Text |
Enter the specialty of the rendering or servicing provider.
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| Address | Text |
Enter the street address of the rendering or servicing provider.
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| City | Text |
Enter the city for the rendering or servicing provider's address.
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| State | Text |
Enter the state for the rendering or servicing provider's address.
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| Zip Code | Text |
Enter the zip code for the rendering or servicing provider's address.
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| NPI Number | Text |
Enter the National Provider Identifier (NPI) number of the rendering or servicing provider.
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| Tax ID Number | Text |
Enter the Tax ID number of the rendering or servicing provider.
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| Phone Number | Text |
Enter the phone number of the rendering or servicing provider.
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| Fax Number | Text |
Enter the fax number of the rendering or servicing provider.
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| Starting Service Date | Date |
Enter the date the service began.
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| Ending Service Date | Date |
Enter the date the service ended, if known.
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| Office | Checkbox |
Check this box if the service was provided in an office setting.
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| Home | Checkbox |
Check this box if the service was provided in the patient's home.
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| Assisted Living | Checkbox |
Check this box if the service was provided in an assisted living facility.
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| Group Home | Checkbox |
Check this box if the service was provided in a group home.
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| Inpatient Hospital | Checkbox |
Check this box if the service was provided in an inpatient hospital setting.
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| Outpatient Hospital | Checkbox |
Check this box if the service was provided in an outpatient hospital setting.
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| Nursing Facility | Checkbox |
Check this box if the service was provided in a nursing facility.
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| Custodial Care Facility | Checkbox |
Check this box if the service was provided in a custodial care facility.
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| ICF/DD | Checkbox |
Check this box if the service was provided in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/DD).
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| Other Place of Service | Checkbox |
Check this box if the service was provided in a place not listed above.
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| Other Place of Service | Text |
If 'Other' is selected as the place of service, describe the specific location.
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| Out-of-network Yes | Radiobutton |
Check this box if the service is being requested out-of-network.
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| Out-of-network No | Radiobutton |
Check this box if the service is not being requested out-of-network.
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| In-network provider not accepting new patients | Checkbox |
Check this box if the reason for out-of-network request is that an in-network provider is not accepting new patients.
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| In-network provider not available | Checkbox |
Check this box if the reason for out-of-network request is that an in-network provider is not available.
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| Patient request | Checkbox |
Check this box if the reason for out-of-network request is due to a patient request.
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| Specialized procedure/Area of expertise | Checkbox |
Check this box if the reason for out-of-network request is due to a specialized procedure or area of expertise.
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| Timely access to provider | Checkbox |
Check this box if the reason for out-of-network request is for timely access to a provider.
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| Other Out-of-network Reason | Checkbox |
Check this box if the reason for out-of-network request is not listed above.
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| Other Out-of-Network Reason | Text |
If 'Other' is selected as the reason for out-of-network service, provide a detailed explanation.
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| Discharge Planning Yes | Radiobutton |
Check this box if the service is needed for discharge planning.
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| Discharge Planning No | Radiobutton |
Check this box if the service is not needed for discharge planning.
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| Discharge Date | Date |
Enter the date of discharge.
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| ICD Code 1 | Text |
Enter the first International Classification of Diseases code.
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| ICD Code 2 | Text |
Enter the second International Classification of Diseases code.
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| ICD Code 3 | Text |
Enter the third International Classification of Diseases code.
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| ICD Code 4 | Text |
Enter the fourth International Classification of Diseases code.
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| ICD Code 5 | Text |
Enter the fifth International Classification of Diseases code.
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| ICD Code 6 | Text |
Enter the sixth International Classification of Diseases code.
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| ICD Code 7 | Text |
Enter the seventh International Classification of Diseases code.
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| ICD Code 8 | Text |
Enter the eighth International Classification of Diseases code.
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| CPT/HCPCS Code 1 | Text |
Enter the first CPT or HCPCS code for the service.
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| Description 1 | Text |
Provide the description for the first CPT or HCPCS code.
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| Modifier 1.1 | Text |
Enter the first modifier for the first CPT or HCPCS code.
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| Modifier 2.1 | Text |
Enter the second modifier for the first CPT or HCPCS code.
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| Quantity 1 | Number |
Enter the quantity for the first service or procedure.
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| Unit Type 1 | Text |
Enter the unit type for the first service or procedure.
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| Total Billable Units 1 | Number |
Enter the total billable units for the first service or procedure.
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| CPT/HCPCS Code 2 | Text |
Enter the second CPT or HCPCS code for the service.
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| Description 2 | Text |
Provide the description for the second CPT or HCPCS code.
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| Modifier 1.2 | Text |
Enter the first modifier for the second CPT or HCPCS code.
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| Modifier 2.2 | Text |
Enter the second modifier for the second CPT or HCPCS code.
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| Quantity 2 | Number |
Enter the quantity for the second service or procedure.
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| Unit Type 2 | Text |
Enter the unit type for the second service or procedure.
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| Total Billable Units 2 | Number |
Enter the total billable units for the second service or procedure.
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| CPT/HCPCS Code 3 | Text |
Enter the third CPT or HCPCS code for the service.
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| Description 3 | Text |
Provide the description for the third CPT or HCPCS code.
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| Modifier 1.3 | Text |
Enter the first modifier for the third CPT or HCPCS code.
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| Modifier 2.3 | Text |
Enter the second modifier for the third CPT or HCPCS code.
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| Quantity 3 | Number |
Enter the quantity for the third service or procedure.
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| Unit Type 3 | Text |
Enter the unit type for the third service or procedure.
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| Total Billable Units 3 | Number |
Enter the total billable units for the third service or procedure.
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| CPT/HCPCS Code 4 | Text |
Enter the fourth CPT or HCPCS code for the service.
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| Description 4 | Text |
Provide the description for the fourth CPT or HCPCS code.
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| Modifier 1.4 | Text |
Enter the first modifier for the fourth CPT or HCPCS code.
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| Modifier 2.4 | Text |
Enter the second modifier for the fourth CPT or HCPCS code.
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| Quantity 4 | Number |
Enter the quantity for the fourth service or procedure.
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| Unit Type 4 | Text |
Enter the unit type for the fourth service or procedure.
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| Total Billable Units 4 | Number |
Enter the total billable units for the fourth service or procedure.
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| CPT/HCPCS Code 5 | Text |
Enter the fifth CPT or HCPCS code for the service.
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| Description 5 | Text |
Provide the description for the fifth CPT or HCPCS code.
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| Modifier 1.5 | Text |
Enter the first modifier for the fifth CPT or HCPCS code.
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| Modifier 2.5 | Text |
Enter the second modifier for the fifth CPT or HCPCS code.
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| Quantity 5 | Number |
Enter the quantity for the fifth service or procedure.
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| Unit Type 5 | Text |
Enter the unit type for the fifth service or procedure.
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| Total Billable Units 5 | Number |
Enter the total billable units for the fifth service or procedure.
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| CPT/HCPCS Code 6 | Text |
Enter the sixth CPT or HCPCS code for the service.
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| Description 6 | Text |
Provide the description for the sixth CPT or HCPCS code.
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| Modifier 1.6 | Text |
Enter the first modifier for the sixth CPT or HCPCS code.
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| Modifier 2.6 | Text |
Enter the second modifier for the sixth CPT or HCPCS code.
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| Quantity 6 | Number |
Enter the quantity for the sixth service or procedure.
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| Unit Type 6 | Text |
Enter the unit type for the sixth service or procedure.
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| Total Billable Units 6 | Number |
Enter the total billable units for the sixth service or procedure.
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| CPT/HCPCS Code 7 | Text |
Enter the seventh CPT or HCPCS code for the service.
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| Description 7 | Text |
Provide the description for the seventh CPT or HCPCS code.
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| Modifier 1.7 | Text |
Enter the first modifier for the seventh CPT or HCPCS code.
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| Modifier 2.7 | Text |
Enter the second modifier for the seventh CPT or HCPCS code.
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| Quantity 7 | Number |
Enter the quantity for the seventh service or procedure.
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| Unit Type 7 | Text |
Enter the unit type for the seventh service or procedure.
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| Total Billable Units 7 | Number |
Enter the total billable units for the seventh service or procedure.
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| CPT/HCPCS Code 8 | Text |
Enter the eighth CPT or HCPCS code for the service.
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| Description 8 | Text |
Provide the description for the eighth CPT or HCPCS code.
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| Modifier 1.8 | Text |
Enter the first modifier for the eighth CPT or HCPCS code.
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| Modifier 2.8 | Text |
Enter the second modifier for the eighth CPT or HCPCS code.
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| Quantity 8 | Number |
Enter the quantity for the eighth service or procedure.
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| Unit Type 8 | Text |
Enter the unit type for the eighth service or procedure.
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| Total Billable Units 8 | Number |
Enter the total billable units for the eighth service or procedure.
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| CPT/HCPCS Code 9 | Text |
Enter the ninth CPT or HCPCS code for the service.
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| Description 9 | Text |
Provide the description for the ninth CPT or HCPCS code.
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| Modifier 1.9 | Text |
Enter the first modifier for the ninth CPT or HCPCS code.
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| Modifier 2.9 | Text |
Enter the second modifier for the ninth CPT or HCPCS code.
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| Quantity 9 | Number |
Enter the quantity for the ninth service or procedure.
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| Unit Type 9 | Text |
Enter the unit type for the ninth service or procedure.
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| Total Billable Units 9 | Number |
Enter the total billable units for the ninth service or procedure.
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| CPT/HCPCS Code 10 | Text |
Enter the tenth CPT or HCPCS code for the service.
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| Description 10 | Text |
Provide the description for the tenth CPT or HCPCS code.
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| Modifier 1.10 | Text |
Enter the first modifier for the tenth CPT or HCPCS code.
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| Modifier 2.10 | Text |
Enter the second modifier for the tenth CPT or HCPCS code.
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| Quantity 10 | Number |
Enter the quantity for the tenth service or procedure.
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| Unit Type 10 | Text |
Enter the unit type for the tenth service or procedure.
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| Total Billable Units 10 | Number |
Enter the total billable units for the tenth service or procedure.
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| Primary Diagnosis 1 | Checkbox |
Check this box if the first listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 2 | Checkbox |
Check this box if the second listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 3 | Checkbox |
Check this box if the third listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 4 | Checkbox |
Check this box if the fourth listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 5 | Checkbox |
Check this box if the fifth listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 6 | Checkbox |
Check this box if the sixth listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 7 | Checkbox |
Check this box if the seventh listed ICD Code is the primary diagnosis code.
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| Primary Diagnosis 8 | Checkbox |
Check this box if the eighth listed ICD Code is the primary diagnosis code.
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| General Eligibility | ||
| Patient has documentation of a decline in health status and is not eligible for hospice | Checkbox |
Check this box if the patient has documentation of a decline in health status and is not eligible for hospice.
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| Patient is eligible for hospice but declines | Checkbox |
Check this box if the patient is eligible for hospice but declines.
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| Medi-Cal Insurance | ||
| Medi-Cal | Checkbox |
Check this box if Medi-Cal is applicable as other insurance.
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| Medi-Cal Insurance ID | Text |
Enter the member's Medi-Cal insurance identification number.
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| Medicare Insurance | ||
| Medicare | Checkbox |
Check this box if the member has Medicare insurance.
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| Medicare Insurance ID | Text |
Please enter the Medicare insurance identification number.
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| Member Information | ||
| Last Name | Text |
Enter the member's last name.
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| First Name | Text |
Enter the member's first name.
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| Date of Birth | Date |
Provide the member's date of birth.
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| Alliance Member ID Number | Text |
Enter the Alliance member identification number.
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| Client Index Number (CIN) | Text |
Enter the Client Index Number (CIN).
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| Medicare Beneficiary Identifier (MBI) | Text |
Enter the Medicare Beneficiary Identifier (MBI).
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| Address | Text |
Enter the member's street address.
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| City | Text |
Enter the member's city of residence.
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| State | Text |
Enter the member's state of residence.
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| Zip Code | Text |
Enter the member's zip code.
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| Phone Number | Text |
Enter the member's phone number.
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| Member's Qualifying Condition | ||
| Congestive Heart Failure (CHF) | Checkbox |
Check this box if the member has Congestive Heart Failure (CHF) and meets both condition (a) and condition (b) as described in the form.
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| Chronic Obstructive Pulmonary Disease (COPD) | Checkbox |
Check this box if the member has Chronic Obstructive Pulmonary Disease (COPD) and meets either condition (a) or condition (b) as described in the form.
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| Advanced Cancer | Checkbox |
Check this box if the member has Advanced Cancer and meets both condition (a) and condition (b) as described in the form.
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| Liver Disease | Checkbox |
Check this box if the member has Liver Disease and meets conditions (a) and (b) combined, or condition (c) alone, as described in the form.
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| Advanced Dementia/Alzheimer's Dementia | Checkbox |
Check this box if the member has Advanced Dementia/Alzheimer's Dementia and meets four (4) out of five (5) specified criteria as described in the form.
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| Type of Request | ||
| Retro | Checkbox |
Check this box if the request is granted for eligibility issues or urgent care and is within 90 days of the date of service.
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| Routine | Checkbox |
Check this box if the request is routine and based on Alliance clinical review.
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| Standing Referral | Checkbox |
Check this box if the request is for a standing referral.
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| Urgent | Checkbox |
Check this box if the request is for medical services that need a prompt decision due to an imminent and serious threat to the member's health.
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| Authorization Change Request | Checkbox |
Check this box if the request is to change existing authorized services.
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| Alliance Authorization Number | Text |
Provide the Alliance Authorization Number if this request is an Authorization Change Request.
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