Forms

Claims

You may submit a provider dispute resolution form to:
1. Challenge, appeal or request reconsideration of a claim that has been denied, adjusted or contested.
2. Challenge a request for reimbursement for an overpayment of a claim.
3. Seek resolution of a billing determination or other contractual dispute.
Click HERE to access the form.

Utilization Management

UM Referral Process

Contracted Providers can access Connect to submit referrals
Non-contracted Providers can fill out the UM TAR Form. Please click here to access the form.
To contact the UM Department, please call (323) 417-7741 M – F 8 am to 5 pm

UM Clinical Criteria

To obtain a copy of the UM criteria used please contact the UM department at (323) 417-7741 M – F 8 am to 5 pm
To view the approved UM criteria list, please click here.
To view links to specific criteria, please click here.

Prescription Drug Form

To obtain a copy of the Prescription Drug Form, please click here.
Needs to be sent to UM fax number 323-720-5608

Affirmative Statement

The Risk Bearing Organization (RBO), c/o Altura Management Services, UM decision making is based only on appropriateness of care, service, and the existence of coverage. Additionally, the RBO c/o Altura MSO affirms:
1. It does not award practitioners or other individuals conducting utilization review decisions that result in underutilization.
2. UM decision making is based only on appropriateness of care and service and existence of coverage.
3. It does not specifically reward practitioners or other individuals for issuing denials of coverage.
4. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.
5. Providers and practitioners are not prohibited from acting on behalf of the member
6. Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care.
7. Practitioners are ensured independence and impartiality in making referrals decisions that will not influence the hiring, compensation, termination, promotion, or any similar matters.

Initial Health Assessment

To view the Provider Bulletin regarding Initial Health Assessments, please click here.

Medical Records

To obtain a copy of member medical records, please fax your request to Altura MSO at 323-530-5701.

Standing Referrals

A "standing referral" is defined as, two (2) or more visits to a specialist Care.
1. A condition or disease that requires specialized medical care over a prolonged period of time and is life threatening, i.e. degenerative, disabling HIV infection and AIDS, must receive a referral to a specialist or specialty care center for the purpose of having the specialist coordinate the member’s health care.
To obtain a copy of the Standing Referral policy call the UM department at (323) 417-7741 M – F 8 am to 5 pm

Provider Peer-to-Peer Requests

Altura MSO UM Department has a designated phone line to connect providers with our Physician Reviewers.
This phone line may be used to contact a physician reviewer to discuss adverse determinations
Direct #: 323-597-2928

Comprehensive Perinatal Services Program (CPSP)

Pregnant women who are eligible for Medi-Cal can enroll in CPSP, which includes prenatal medical care, health & nutrition education, as well as support for issues like jobs, emotional well-being, and housing.
Pregnant women and teens can go to CPSP sites and receive temporary Medi-Cal that same day for prenatal care. The patient must then apply for Medi-Cal. No one is excluded based on immigration status. While waiting for the reply from Medi-Cal, the clinic visits will be paid for by Medi-Cal.
For additional program information, visit the CPSP Website
To obtain a copy of the CPSP Provider Handbook, please click here.
To obtain a copy of the CPSP Program Guidelines, please click here.

Case Management Referral Process

Referrals to Case Management (CM) will be accepted via telephone, or e-mail.
1. Telephone: (323) 417-7741 M – F 8 am to 5 pm
2. E-Mail: caremanagementdepartment@alturamso.com
Providers can access the CM Referral Form here.

Post-Stabilization

Hospital/Emergency Room attempting to provide telephonic notification for post-stabilization must call (323) 417-7741 to obtain authorization of post-stabilization care.
Upon calling, follow the prompt selections to the Inpatient Department as a UM representative is available 24 hours a day, 7 days a week.

Palliative Care

Palliative care consists of patient-and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. The provision of palliative care does not result in the elimination or reduction of any covered benefits or services under the RBO c/o Altura MSO contracts and does not affect a member's eligibility to receive and services, including home health services, for which the member would have been eligible in the absence of receiving palliative care.
Palliative care does not require the member to have a life expectancy of six months or less and may be provided concurrently with curative care. A member with a serious illness who is receiving palliative care may choose to transition to hospice care if they meet the hospice eligibility criteria. A member may not be concurrently enrolled in hospice care and palliative care.

Palliative care services may differ per line of business. The RBO c/o Altura MSO will provide care coordination for palliative care services as per federal, state, and Full-Service Health Plan regulatory requirements.

End of Life

As defined by the End-of-Life Option Act, EOL services include consultations and the prescription of an aid-in-dying drug. EOL services are a “carve-out” for Medi-Cal managed care health plans (MCPs) and are covered by Medi-Cal FFS. Beneficiaries are responsible for finding a Medi-Cal FFS physician for all aspects of the EOL benefit.
During an unrelated visit with an MCP physician, a beneficiary may provide an oral request for EOL services. If the physician is also enrolled with the Department of Health Care Services (DHCS) as a Medi-Cal FFS provider, that physician may elect to become the beneficiary’s attending physician as he or she proceeds through the steps in obtaining EOL services. EOL services following the initial visit are no longer the responsibility of the MCP and must be completed by a Medi-Cal FFS attending physician, or a Medi-Cal FFS consulting physician. Alternatively, if the MCP physician is not a Medi-Cal FFS provider, the physician may document the oral request in his or her medical records as part of the visit; however, the MCP physician should advise the beneficiary that following the initial visit he or she must select a Medi-Cal FFS physician in order for all of the remaining Act requirements to be satisfied.
The RBO c/o Altura MSO will ensure any request for EOL services received will be referred to the Full-Service Health Plan.

Sterilization and Informed Consent

All members undergoing sterilization must give written consent via the PM 330 form and receive a copy of the Sterilization Booklet from the DHCS website.
In addition to the PM 330 consent form, a member acknowledgment must be documented in the electronic medical record (EMR) confirming receipt of the booklet by the member.
To obtain a copy of the Sterilization Booklet, please visit the DHCS website
To obtain a copy of the PM 330 form, please click here.

Provider Demographic Changes

If you are already a participating provider and/or facility with AltaMed and/or Omnicare Medical Group and need to notify us of updates or changes to your office or provider/facility information (i.e. address change/update or locations to be added), please contact your assigned Provider Network Administrator for assistance or fill and email the attached form to contracting@alturamso.com. You may validate if your request was completed by checking AltaMed’s and/or Omnicare’s Online Provider Portal.

Forms

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