Find forms that you may need to fill out and return to AlohaCare.
IMPORTANT INFORMATION - QUEST Integration Registration - Effective July 1, 2021, Provider enrollment and registration is required with the Department of Human Services (DHS), Med-QUEST Division to acquire a State of Hawai`i Medicaid ID prior to submitting an application to QUEST Integration Health Plans to proceed with credentialing.
AlohaCare will inactivate our credentialing process upon confirmation as to whether the applicant has not completed DHS Med-QUEST's enrollment and registration process. We will issue a notification to the applicant with regard to our determination if it results in our inability to proceed with credentialing.
- AlohaCare Provider Credentialing Application & Enrollment Form:
- Select the Credentialing Application option if the submission is for a provider or practitioner interested in joining AlohaCare's Network.
- Select Enrollment option of the form if the submission is for the following:
- Adding a Hospitalist or Hospital based Provider (D.O. or M.D.) rendering services in a hospital setting.
- Adding a new location and pay-to for a Credentialed Provider or Practitioner rendering services in an outpatient setting.
The Credentialing Application & Enrollment form must be completed in its entirety, include all forms, required documentation, and must be signed and dated in order for AlohaCare to initiate our Credentialing or enrollment processes.
- Assisted Living
- Behavioral Health Facilities
- Critical Access Hospital / Long Term Care
- Free Standing Infusion Treatment / Therapy Center
- Free Standing Radiology Center
- Free Standing Surgical Center / Ambulatory Surgical Center / Outpatient Surgical Center
- Intermediate Care Facility
- Nursing Home
- Respite Care
- Skilled Nursing Facility
- Substance Abuse Treatment (IOP / LIOP)
- Air Ambulance
- Durable Medical Equipment
- Ground Ambulance
- Home Hospice Agency
- Independent Laboratory
- Specialty Pharmacy
- Adult Day Care
- Adult Day Health
- Community Care Foster Family Home
- Community Integrated Services
- Home Chore Services / Personal Care Agency
- Home Health Agency
- Personal Emergency Response Services
- Expanded Adult Residential Care Home
- AC Online Registration: Sign up to access member eligibility, claim billing and prior authorization information as well as electronic submission of referrals, prior authorization and notifications.
- Address/Contact Update/Change Form
- Update contact or payment information.
- Change the address of an existing practice location.
- Add another practice location to the same group/practice. Please complete the AlohaCare Provider Credentialing Application & Enrollment form if you are Credentialed/Participating with AlohaCare and you are joining a new group/practice.
- Provider Panel Status Update Form: Complete this form to inform AlohaCare about your panel status and let us know whether you have the ability to accept new members.
- Request for Taxpayer Identification Number and Certification (W-9 Form): Fill out the W-9 Form for our files. We’re required to have your taxpayer identification number and certification on record.
- QI Service Coordination Referral Form: Refer a member to Service Coordination.
- Hospice Information for Medicare Part D Plans: Complete this form to update hospice status or to override an "Hospice A3 Reject."
- PCP Change Form: This form lets members change their Primary Care Provider (PCP).
- Waiver of Liability Form: For Medicare Non-Par Providers Only
- Typically appeals are written requests made by providers disagreeing with the resolution of a grievance. Medicare non-par providers may file an appeal for a denial of payment without submitting a grievance first.
- Medicare non-par providers must complete the Waiver of Liability Form agreeing not to bill an enrollee regardless of the outcome of the appeal.
- Adverse Event: Report all incidents and events that harm our members who receive long-term services and supports (LTSS).
- Harm can include lack of prescribed services (i.e. caregiver doesn't show up).
- An Adverse Event is an occurrence that may cause harm to a member or LTSS provider. The Adverse Event indicates risk (i.e. abuse, neglect, exploitation) to a member to LTSS provider's health or welfare.
- Injury and Illness Form: Please assist member with completing this form if their injury or illness is related to a work or automotive incident or accident.
- Older Adult Provider Assessment Form: Provider fills out a form about the patient's Advance Care Planning, Functional Status, Assessment, Pain Assessment, and Medication Review for older adults.
- Community Integration Services (CIS) - Supportive Housing Services - These services, when paired with affordable housing, are a way to help individuals experiencing homelessness to locate and stay in housing.
- Pharmacy Prior Authorization: Prior Authorization requests for drugs covered under the pharmacy benefit (generally dispensed by a pharmacy to a patient for self-administration)
- Fax or Mail a Paper Form:
- Electronic Prior Authorization (ePA) through your Electronic Health Record (EHR) tool or one of the following ePA portals: