Forms

IMPORTANT INFORMATION - QUEST (Medicaid) 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 (Medicaid) 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:
  • As a new provider, please click on the link above to complete the required information and submit. Once received, a link to AlohaCare Provider HUB will be emailed to you from credentialing@verity.cloud as well as instructions on how to create your credentials to complete your application.  
    
    

    This online provider enrollment applies to the following provider types:

    Acute Care Nurse Practitioner	Licensed Mental Health Counselor
    Advanced Practice Registered Nurse	Licensed Practical Nurse
    Applied Behavioral Analyst	Medical Doctor
    Audiologist	Nurse Practitioner
    Board Certified Behavior Analyst	Occupational Therapist
    Certified Diabetes Care and Education Specialist	Ophthalmologist/Optometrist
    Certified Nurse Assistant	Physical Therapist
    Certified Nurse Midwife	Physician Assistant
    Certified Registered Nurse Anesthetist	Podiatrist
    Doctor of Osteopathic Medicine	Psychiatrist
    Doctor of Osteopathic Medicine	Psychologist
    Doctor of Pharmacy	Registered Dietitian
    Family Nurse Practitioner	Registered Nurse
    Licensed Clinical Social Worker	Speech-Language Pathology
    Licensed Marriage & Family Therapist

• Facility and Ancillary Credentialing Application
• Long Term Services and Support (LTSS) / Home & Community Based Services (HCBS) Credentialing Application & Enrollment Form: This application and enrollment form is for all medical and behavioral health treatment facilities, as well as facilities/providers that provide long term services & support (LTSS) and Home and Community Based Service (HCBS) reflected within the table below.

• 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. 
• 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.
• Adult Health Risk Assessment
• Child Health Risk Assessment
• Circadian Referral Form 
  
• Hospice Information for Medicare Part D Plans: Complete this form to update hospice status or to override an "Hospice A3 Reject."
  
• 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.
  
• PCP Change Form: This form lets members change their Primary Care Provider (PCP).
  
• Provider Address Update and 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.
• QI Service Coordination Referral Form: Refer a member to Service Coordination.
  
• 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. 
• SSBCI Provider Attestation Form: AlohaCare requires a referral and attestation from a treating provider to enroll a member in Special Supplemental Benefit for Chronically Ill (SSBCI).
  
• 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.
    

Paillative Care: Community palliative care offers an extra layer of support and specialized medical care, provided by an interdiciplinary team, for individuals living with serious illnesses.

• Comprehensive Community Palliative Care Assessment Supplement Form
• Comprehensive Community Palliative Care Health Action Plan (HAP) Supplement Form
• Community Palliative Care Services: Face Sheet
• Palliative Care Program Eligibility Screening Tool
• Palliative Care - Billing Guideline

CIS Housing navigation (previously called CIS) supports are intended to help members attain and maintain safe, affordable housing. Housing navigation includes both pre-tenancy support and tenancy sustaining services.

CIS Medical respite is designed to support members with short-term needs to recover from or prepare for clinical events in safe, supportive short-term housing. this includes short-term pre-procedure housing, short-term recuperative care, and short-term post-hospitalization housing.

• CIS﹢Referral Form
• CIS﹢Member Consent Form
• CIS﹢Action Plan
• CIS﹢Member Assessment and Reassessment Tool
• CIS﹢Medical Respite Authorization Form
• CIS﹢Billing Guidelines for Housing Navigation
• CIS﹢Member Reimbursement Form
• CIS﹢Drug Coverage Request Form 
• CIS﹢Physician Administered Drug Request Form
• CIS﹢Medical Respite Billing Guidance
• CIS﹢Discharge Form

• Request for Prior Authorization/Notification Request: Refer your patients to out of network specialists or request authorization for services/procedures on the prior authorization list. 
• Request for Retro Authorization: A provider may request for a Retro Authorization only if there were extenuating
  circumstances that prohibited their ability to follow AlohaCare’s processes and procedures.

• Prior Authorization Request Form for Substance Use Disorders: For Behavioral Health providers only. Complete this form for BH/CD services that require prior authorization.
• Notification of Termination of Behavioral Health Treatment: For Behavioral Health Providers Only: Complete this form when terminating outpatient professional services, or chemical dependency treatment.  
• Outpatient Psychological Testing Request: For Behavioral Health Providers Only. Complete this form to request outpatient professional psychological or neuropsychological testing.
• Request for Applied Behavioral Analysis (ABA) Services: Request ABA services. 
• Request to Extend End Date of Authorization: Request to extend the end date of a Behavioral Health authorization.
• ACT 37 - Notice of Non-Disclosure Form - Establishes privacy provisions found in Act. 37.

• 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:
  
  • AlohaCare PA Form (QUEST version)
  • OptumRx PA Request Form (Medicare version)

• Electronic Prior Authorization (ePA) through your Electronic Health Record (EHR) tool or one of the following ePA portals:
  
  • Surescripts
  • Prompt PA

• Physician Administered Drug Request Form: Prior authorization requests for drugs (J codes & Q codes) covered under the medical benefit (generally an outpatient administration by a healthcare professional) 

• Drug List Addition / Clinical Criteria Change Request Form: Requests for OptumRx's Pharmacy and Therapeutics (P&T) Committee to consider adding or removing a drugs on the formulary or changing a clinical criteria policy

Notify AlohaCare when an AlohaCare member is diagnosed with pregnancy. Early notification helps ensure timely care coordination, member outreach, and continuity of benefits.
Providers should submit the Member Pregnancy Notification Form within 24 hours of confirming pregnancy and include:

• Expected Date of Delivery (EDD)
• Identified high-risk pregnancy factors, if applicable
• Name of the provider managing obstetrical care
• Member and provider contact information

Submit the completed form through the AlohaCare Provider Portal (AC Online) or by fax as indicated on the form. AlohaCare will provide confirmation of receipt. 

• Travel Request Form - Refer your patients for non-emergent medically necessary transportation services, On-island, Off-island, and Out of State.
• Certification of Medical Necessity Mode of Transportation: Certification form for medical provider to verify member's mode of transportation and medically necessary considerations for travel.

• DHS 1128 form - Disability Report form shall be initiated by a provider when an individual applies for medical assistance on the basis of blindness or disability and a determination is required.
  • DHS 1128 form Instructions
• DHS 1127 form - Medical History and Disability Statement shall be completed and submitted to the Aid to Disabled Review Committee (ADRC) to assist in the disability determination by evaluating an individual’s medical profile, education level, and previous work experience.
  • DHS 1127 form Instructions