Complete the Inpatient Out-of-Network Service Authorization Request (OON SAR) and email to the Alliance Health Utilization Management Department at UMOutofNetwork@AllianceHealthPlan.org.

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The form must be submitted to Alliance Health within 72 hours of admission. A UM Care Manager will contact the requesting facility to discuss the plan of care. If it is determined that medical necessity is met and the request is approved, the facility will be contacted by the Alliance Health Contracts Department to initiate a Single Client Application/Agreement.

Here is the website for Medicaid Clinical Coverage Policy 8B Inpatient Behavioral Health Services.

Here is the website to find the Certificate of Need: Medicaid Inpatient Psychiatric Services Under Age 21.

Authorization of services does not guarantee payment for services rendered.

Alliance Health makes every effort to first link consumers with network providers, but will consider enrolling an out-of-network provider or amending a currently contracted provider’s contract if a network provider is not available or accessible to the enrollee.

The Provider will submit a Provider Application Request, which will collect information about the provider type, specialties, services requesting to provide, location and information regarding the consumer. Please include any specialty or pertinent information related to request for review and submit the request to ProviderNetwork@AllianceHealthPlan.org.

Geo-mapping will be completed and provider network staff will review the information and will identify if there is a network gap or if there is a network provider that is currently contracted for the service being requested,  who meets the thirty (30) mile radius requirement and can provide the approved service. If there was no consumer identified in the request the provider will be informed that at this time the network is closed and based on a review of provider type and location that we are unable to move forward with the application process. If there was a consumer identified, the provider will be informed that at this time our network is closed and based on a review of provider type Alliance Health has current providers available to serve the consumer(s) and a list of contracted providers with contact information will be sent to the provider within seven (7) calendar days.

If there are no network providers who can provide the approved service within the thirty (30) mile radius and the treatment is client specific an Out-of-Network Single Client Application/Agreement will be pursued:

• Provider will be notified they are approved to submit an Out-of-Network SAR to determine medical necessity.
• The provider will complete and email the Out-of-Network SAR, along with supporting clinical documentation (i.e. comprehensive clinical assessment, person centered plan, service order) to the Alliance Health Utilization Management Department at UMOutofNetwork@AllianceHealthPlan.org within two weeks of receiving the OON SAR.
• UM will review the SAR for medical necessity. If the UM Care Manager recommends that the treatment is client specific and medically necessary, the UM Department will submit the approved SAR to Provider Network Contracts department in order for the Single Client Application/Agreement or Contract Amendment to be generated. The Contract Administrator will email the Out-of-Network Single Client Application/Agreement and additional required documents to the out-of-network provider for completion. This will need to be completed and returned to the Contract Administrator within 14 calendar days in order to fully execute the agreement and authorization request.

Authorization of services does not guarantee payment for services rendered.