Community Care Services
Overview & Resources
Adult Medicaid members age 18 years or older with a diagnosis of serious mental illness (SMI) or a severe and persistent mental illness (SPMI) may be eligible for additional behavioral health services from the Community Care Services (CCS) program offered by AlohaCare
Join the AlohaCare Provider Network
Providers can apply to join our network by completing AlohaCare’s Provider Hub - AlohaCare Provider Credentialing Application & Enrollment Form
Once credentialing and contracting process is completed, providers can register for our secure provider portal (AC Online) to check member’s eligibility status, request prior authorization electronically, review claims status and more.
Sign up:
Provider Resources
AlohaCare aims to ensure that claims are handled as efficiently as possible. Providers can help facilitate timely claim payment by having an understanding of our processes and requirements. The following materials may change periodically, so please check for updates.
Reimbursement Policies
AlohaCare periodically reviews reimbursement policies to mirror industry standards and updates from the Centers for Medicare and Medicaid and other nationally recognized health and medical societies.
AlohaCare Community Care Services (CCS) coordinates with Department of Health Alcohol and Drug Abuse Division (DOH-ADAD) to help meet the needs of our members with substance use disorders by utilizing the 988 Hawaii CARES line to assist with access to the Hawaii CARES Network. For help referring members to these types of providers for substance use disorder treatment, providers can contact our Customer Service Representatives at 808-450-3386 or toll-free 1-888-397-9899. TTY/TDD users can call 1-877-447-5990. Alternatively, providers can access substance use disorder treatment 24/7 by calling the 988 Hawaii CARES line:
Oahu: 1-808-832-3100
Neighbor Islands: 1-800-753-6879
Text: 1-808-808-1627
Forms
AlohaCare Community Care Services (CCS) Formulary
AlohaCare Community Care Services (CCS) covers all medically necessary behavioral health medications. We use a Formulary, which is a list of the drugs that we prefer our providers to prescribe. AlohaCare CCS also covers the over-the-counter drugs (e.g., diphenhydramine, vitamin B complex, and thiamine) listed on our Formulary. Your patient will need a prescription for an over-the-counter drug to be covered by AlohaCare CCS.
You can search our Drug Finder to find drugs that are on our Formulary.
To request, add, or remove a drug from the Formulary or to change a Clinical Criteria, submit a request using the Drug List Addition/ Clinical Criteria Request Form. Requests will be presented at the next Pharmacy & Therapeutics (P&T) Committee meeting for review and consideration.
Some drugs require a prior authorization (PA) to explain to us why a specific medication or a certain amount of a medication is needed. We must approve the request before the member can get the medication. Reasons why we may prior authorize a drug includes, but is not limited to:
- There is a generic or pharmacy alternative drug available;
- The drug can be misused/abused; or
- There are other drugs that must be tried first.
Some drugs may also have a quantity (amount) limit, step-therapy, or an age limit.
Drugs for non-behavioral health conditions, investigational or experimental drugs, or drugs that are for any indication that is not medically accepted are not covered.
A complete list of non-covered and excluded drugs can be found in the Drugs That Are Not Covered by AlohaCare Community Care Services (CCS) section located on the CCS Pharmacy Services page.
Electronic prior authorization (ePA) is preferred method for PA submission for AlohaCare CCS
Alternatively, prescribers can send requests using their current electronic health record/electronic medical record (EHR/EMR) system or submit a Prescription Drug Prior Authorization Request Form or Physician Administered Drug Request Form.
For questions regarding prior authorization requests, please contact AlohaCare Pharmacy Department at 808-973-7418 or toll-free at 1-866-973-7418.
AlohaCare requires the use of generic drugs if they are available. If you believe that it is medically necessary for your patient to have a brand name drug, you may submit a prior authorization request for review. AlohaCare will determine whether to approve the brand name medication.
Our formulary and list of medications that require prior authorization can change, so it is important for you or your patient to check this information when your patient needs to fill or refill a medication.
For our member’s convenience and to encourage medication adherence, we cover up to a 100-day supply of generic maintenance medications. You can search our Drug Finder to find drugs eligible for this extended supply.
For questions about pharmacy processing and claim overrides, contact the OptumRx Member Services at 1-877-795-4521 or visit www.optumrx.com (click on Health Care Professionals).
Pharmacy Billing Information for AlohaCare CCS
BIN: 610011 | PCN: STATE | GROUP: ALOHACCS
AlohaCare CCS Billing Payer Sheet
AlohaCare covers partial fills to synchronize medication refills to the same day each month. This only applies to maintenance medications that are normally covered for the member (the medication is on the formulary without restrictions or the member has an active prior authorization) and excludes Schedule II and III controlled substances.
For refill date synchronization, the pharmacy should calculate the days’ supply needed in a partial fill so that future fills of maintenance medications will fall on the same day.
If a claim rejects with NCPDP Reject Code 79 (Refill Too Soon), the pharmacy may override the reject with Submission Clarification Code (SCC) 61 (Synchronization Fill - Shortened Days Supply).
Mail Order & Home Delivery
Home Delivery is a service that AlohaCare offers to our AlohaCare CCS members. With Home Delivery, members have the convenience of getting maintenance medications delivered directly to their home. The Home Delivery Program is administered through OptumRx Home Delivery Pharmacy.
To send electronic prescriptions for home delivery/mail order select OptumRx Home Pharmacy in your ePrescribing platform. Please note that the pharmacy address will display as Overland Park, KS
Optum Specialty Pharmacy is our Preferred Specialty Pharmacy.
While Optum Specialty Pharmacy is our preferred specialty pharmacy provider, prescribers have the option to request that prescriptions be filled by any willing specialty pharmacy provider of their choosing.
How to Send a Prescription Referral:
- E-prescribe: Find Optum Specialty Pharmacy in your electronic medical records (EMR) system.
Learn more about Optum Specialty Pharmacy at Optum Specialty Pharmacy.
Alternative Specialty Pharmacy Providers
Sometimes, certain medications are not available through Optum Specialty Pharmacy. For example, some medications are only available at other pharmacies in a limited distribution network. In these cases, we will cover medications through a different specialty pharmacy.
Pharmacy benefit (pharmacy dispensed drugs) prior authorization requests & status inquiries | AlohaCare Pharmacy Department (Prescribers Only) - Phone: 808-973-7418 or toll-free 866-973-7418
- Fax: 1-866-728-0233 or 1-877-252-5224
- Hours: 8 AM to 5 PM, Monday to Friday
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AlohaCare CCS claims processing or overrides | OptumRx Member Services (Pharmacies Only) - Phone Number: 1-844-368-8732
- Hours: 24 hours, 7 days a week
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Medical benefit (physician administered drugs) prior authorization request & status inquiries | AlohaCare Pharmacy Department (Prescribers Only) - Phone: 808-973-7418 or toll-free 866-973-7418
- Fax: 1-866-728-0233 or 1-877-252-5224
- Hours: 8 AM to 5 PM, Monday to Friday
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Quality
The AlohaCare CCS Quality Improvement and Assessment Performance (QAPI) program, aligned with our mission, strives to advance the equitable delivery of safe, accessible and available high-quality care and elevate member and provider experience. Furthermore, in partnership with our members, community partners, practitioners and providers, we make every effort to make AlohaCare a leader in ensuring that everyone has a fair and just opportunity to be as healthy as possible while attaining health equity for all.
The AlohaCare Community Care Services (CCS) Quality Improvement (QI) program program uses the Healthcare Effectiveness Data and Information Set (HEDIS®) to measure our behavioral health outcomes performance. HEDIS® is a mandatory process that occurs annually. Some measures we monitor include, but not limited to, the following:
- Follow-Up after Emergency Department Visit for Mental Illness
- Follow-Up after Emergency Department Visit for Substance Use
- Follow-Up after High-Intensity Care for Substance Use Disorder
- Follow-Up after Hospitalization for Mental Illness
- Pharmacotherapy for Opioid Use Disorder
- Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Using Antipsychotic Medications
- Adherence to Antipsychotic Medications for Individuals with Schizophrenia
- Initiation and Engagement of Substance Use Disorder Treatment
Annually, the AlohaCare Community Care Services (CCS) Quality Improvement (QI) program conducts at least one member experience survey which provides a general indication of how well we are doing to meet members’ expectations. The Adult version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a standardized survey used to collect information on member satisfaction and experience with healthcare services, practitioners and providers, and settings. The survey questions reflect members’ overall satisfaction on:
- Rating of All Health Care
- Rating of Health Plan
- Rating of Personal Doctor
- Rating of Specialist Seen Most Often
Other key areas include questions on:
- Customer Service
- Getting Care Quickly
- Getting Needed Care
- How Well Doctors Communicate
- Coordination of Care
The AlohaCare CCS program may also conduct an Experience of Care and Health Outcomes (ECHO) survey, which is another standardized survey tool designed to measure member experiences with behavioral health care, including mental health and substance abuse treatment, as well as outcomes for that care.
Fraud, Waste & Abuse
AlohaCare wants to ensure that we are all working together to protect the resources available to serve our members. Health care fraud, waste and abuse (FWA) hurts everyone including members, providers, and taxpayers. AlohaCare is committed to protecting the integrity of the healthcare system in the fight against FWA by preventing, detecting and correcting instances of FWA. Please help us by reporting questionable activities you believe could be potential FWA.
Provider Fraud, Waste & Abuse
Some examples of provider activity that is monitored for fraud, waste and abuse:
- Prescribing drugs, equipment or services that are not medically necessary
- Billing more than once for the same service
- Intentionally using improper medical coding to receive a higher rate of reimbursement
- Billing for services not provided
- Scheduling more frequent return visits than are needed
- Unbundling services to obtain higher reimbursement
- Purchasing drugs from outside the U.S.
- Prescribing high quantities of controlled substances without medical necessity
Member Fraud, Waste & Abuse
AlohaCare monitors member activity for fraud, waste and abuse. Some examples are:
- Inappropriately using services such as selling prescribed narcotics, or seeking controlled substances from multiple providers or multiple pharmacies
- Sharing a member ID card
- Obtaining unnecessary equipment/supplies
- Changing prescription forms to get more than the amount of medication prescribed by their physician
- Member receiving services or picking up prescriptions under another person's ID (identity theft)
Pharmacy Fraud, Waste & Abuse
Examples of pharmacy fraud, waste and abuse:
- Prescription drugs not dispensed as written
- Submitting claims for a more expensive brand name drug when a less expensive generic prescription is dispensed
- Dispensing less than the prescribed quantity without arranging for the additional medication to be received with no additional dispensing fees
- Splitting prescriptions into two orders to seek higher reimbursement
- Dispensing expired, fake, diluted or illegal drugs
- Billing for prescriptions not filled or picked up
Report Fraud, Waste & Abuse
- Options that are anonymous:
- Call our 24/7 hotline at 855-973-1852
- Write to us or use our FWA Reporting Form and mail to:
AlohaCare
ATTN: Special Investigations Unit
1357 Kapiolani Blvd,
Suite G101
Honolulu, HI 96814
- Options that are not anonymous:
- Email us at fraud@alohacare.org
- Contact customer service toll-free at 1-800-434-1002
- Fax: 808-973-7410
- Report to your assigned AlohaCare Provider Representative
- When reporting, please give a detailed description of the activity, including:
- Name and contact info of person believed to be committing FWA
- Date of suspicious activity
- Issue of concern and any other pertinent information
- Your contact info, if anonymity is not requested
Note: You may report anonymously, however if you do not provide your identity, we will not be able to contact you for more information, if needed.