CurrentAlliant HealthPolicy N/A
Certificate of Coverage (Group Health Plan)
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This document is the Certificate of Coverage for the 2026 SimpleCare Group Health Plan issued by Alliant Health Plans and governs eligibility, benefits, notices, and administrative procedures for Members and their eligible dependents under the Group Health Care Contract.
Policy Summary
PayerAlliant Health
PolicyCertificate of Coverage (Group Health Plan)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionYour in‑network provider or hospital should call Alliant Medical Management for Prior Authorization before services or admission; members must call for out‑of‑network admissions at (800) 865-5922.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
1-866-403-2785Client Services phone
AlliantPlans.comWebsite
26Dependent age limit
180 daysClaim filing window
72 hoursUrgent auth timeframe
7 daysPre-service auth timeframe
Coverage rules, eligibility, and medical necessity
General coverage and prior authorization
Coverage under the Group Health Care Contract and this Certificate governs benefits; Prior Authorization requirements and exceptions are specified below.
Coverage is governed by the Group Health Care Contract and this Certificate; benefits are subject to the exceptions, limitations, and provisions of the Contract (the Certificate replaces prior Certificates).
In-Network benefits are provided by Alliant; Members may return the policy within 10 days for a premium refund (any benefits paid will be deducted).
Prior Authorization: Providers should contact Alliant Medical Management at (800) 865-5922 for Prior Authorization before services or admission; Members are responsible for obtaining Prior Authorization when using Out-of-Network Providers.
Prior Authorization approvals are not guarantees of payment and apply only to the services listed in the request or on AlliantPlans.com. Approval for one service does not extend to other services.
Verification of benefits via Client Services or the website is not a guarantee of payment; if Prior Authorization is required, call the Prior Authorization number.
Eligibility, enrollment, and related coverage rules
Rules about who is covered, how and when coverage begins, enrollment windows, special enrollments, and continuation during leave.
Subscriber coverage: Coverage is provided to the Subscriber (Member) and only to Dependents reported to Alliant and added via a proper enrollment application.
Dependent eligibility: Eligible Dependents may include spouse (if not legally separated), dependent children through the end of the month they attain age 26, adopted children from assumption of legal responsibility, stepchildren, children covered by court order, and permanently disabled dependents (disability certification rules apply).
Open Enrollment and changes: Members may change coverage options during the annual enrollment period; Dependents may be added during Open Enrollment or qualified Special Enrollment Periods.
Special Enrollment Events
- Loss of qualifying health coverage (not including voluntary termination or failure to pay premiums).
- Change in household size (e.g., marriage, birth, adoption, placement for adoption).
- Change in primary residence or newly gaining eligibility for ICHRA/QSEHRA.
- Enrollment or plan error discovered by the employer or plan.
Newborn and foster child temporary coverage (Tennessee): Newborns and newly adopted children are covered for 31 days from birth or date of legal assumption; to continue coverage an application and premium must be received within 31 days (late receipt within 60 days reinstates retroactively).
Foster children: Foster children are not automatically covered; Member must provide confirmation of a valid foster parent relationship and submit application and premium within 31 days (or within 60 days to reinstate retroactively).
Medicaid/CHIP special enrollment: If Medicaid/CHIP coverage is lost or a state premium assistance subsidy becomes available, special enrollment is permitted within the allotted time period.
When coverage begins: Coverage effective date is the date after the Group's waiting period has been met; employer waiting period may not exceed 90 days. Employee and Dependent effective dates depend on employment active status and qualifying events (marriage, birth, placement for adoption, QMCSO/NMSN or court order).
Family and Medical Leave (FMLA): Coverage may be continued up to 12 weeks during employer-approved medical leave if the Employee pays required contribution share. Notify employer of qualifying life events (divorce, death, dependent aging out, disability) as required.
Coverage-impact rules
Eligibility continuation, termination, portability, portability-related notices, and benefit extensions under state and federal rules.
Portability/HIPAA: If a newly eligible person had prior group coverage within the previous 90 days, HIPAA portability may allow immediate eligibility subject to employer waiting periods.
Certification of prior coverage: Members may request certification of prior creditable coverage within 24 months after losing coverage.
Group termination: The Group contract may be canceled for nonpayment of premiums, fraud, insufficient participation, or policy form termination; notice provisions (e.g., 60–90 days) apply and replacement options may be offered.
Individual termination: Coverage ends upon employment termination, failure to meet eligibility, Group Contract cessation, or failure to pay required contributions; child coverage ends at month child attains age 26; rescission allowed for fraud/intentional misrepresentation with 30 days' notice.
State continuation (Tennessee): Employees continuously enrolled 3+ months may elect continuation for remainder of month plus three additional months by paying premiums, subject to exclusions and eligibility rules; other special continuation rules for divorce/death/pregnancy may apply.
Federal continuation (COBRA/USERRA): COBRA available for employers with 20+ employees for 18–36 months depending on qualifying event; notification and election timelines (employer notify 30 days, member notify 60 days, election within 60 days, initial premium within 45 days) and premium rules (up to 102% or up to 150% in disability extension months) apply. USERRA provides military leave continuation up to 24 months and reemployment protections when requirements met.
COBRA qualifying events and second-event extension: Second qualifying events may extend coverage (e.g., disability extension to 29 months; second qualifying event may extend to max 36 months for dependents).
When COBRA ends: COBRA ends at earliest of maximum period, nonpayment, becoming covered under another group plan, Medicare entitlement, or Group termination of welfare plans with Alliant.
Extension of benefits for total disability: If the Group Contract terminates, Alliant may extend major medical benefits at no cost for a totally disabled Subscriber for the disabling condition up to 12 months from termination (definition of total disability applies).
Verification of benefits: Members or authorized providers may verify benefits via Client Services, but verification is not a guarantee of payment; if Prior Authorization is required, call the Prior Authorization number.
Coverage criteria and rules
Coverage and benefit extension rules, Prior Authorization applicability, authorization timeframes, MAC/QPA determinations, and member cost-sharing basics.
Extended benefits: Alliant may extend benefits at no cost for a Member who is totally disabled and under a physician's care; extension applies only to Covered Services related to the disabling condition and ends when disability ends, one year after coverage ends, or when payment limits are reached.
Prior Authorization limitations: Prior Authorization is not a guarantee of coverage if Member is not covered at time of service, benefits exhausted, fraud/misrepresentation, or service is not a Covered Service; approvals apply only to services requested/listed and do not guarantee future claim payment.
Authorization timeframes: Urgent decisions within 72 hours; Pre-service decisions within 7 calendar days (may extend another 7 days); Concurrent decisions within 24 hours for urgent requests or within 7 days for other concurrent requests; Post-service reviews decided within 30 calendar days.
MAC/QPA determination: Out-of-Network reimbursement is based on the plan's MAC; QPA/MAC for emergency and surprise-billing situations is calculated per the No Surprises Act (QPA options include median contracted rate as of 1/31/2019 adjusted for inflation, state APCD, or alternate derived amount).
Member cost share: Member responsibility (deductible, copayment, coinsurance) may be based on the MAC and differs for In-Network versus Out-of-Network providers. Non-Covered Services are not reimbursed and are the Member's responsibility.
Coverage and payment criteria
Payment determination, member cost sharing details, authorized service exceptions, claims filing timelines, and audit-related denial risks.
MAC/QPA computation: MAC or QPA for emergency and surprise-billing situations is calculated per No Surprises Act methods (median contracted rate as of 1/31/2019 adjusted for inflation, APCD, or alternate derived amount).
Member cost sharing specifics: Cost share (deductible, copayment, coinsurance) may be applied to the MAC and may be higher for Out-of-Network care; balance billing protections vary by network status.
Authorized Services for Out-of-Network Providers: In cases where no In-Network Provider is available, Alliant may authorize application of In-Network cost share to an Out-of-Network Covered Service if requested in advance; Member may still be liable for difference between MAC and provider charge (illustrative example provided).
Care outside the U.S.: Non-emergency care abroad is not covered; emergency care outside the U.S. may be covered and payment is based on MAC; benefits cannot be assigned to foreign providers.
Claims filing timelines and payment: Members/providers must submit accurate claim information; claims must be submitted within 180 days of service; Alliant will notify within specified timelines for missing information and pay interest at 12% per year if timelines are not met.
Balance billing rules: In-Network providers are prohibited from balance billing; Out-of-Network providers may bill excess charges subject to MAC and applicable surprise-billing protections.
Medical bill review and audits: Alliant may audit claims and deny payment for services not ordered by a physician, not documented, routine/unbundled, upcoded, or otherwise non-compliant with coding and medical necessity rules. Providers must submit Clean Claims.
Coding and billing compliance: Claims are adjudicated against AMA/CMS/NCCI/PFS and other federal and clinical guidance; billing mistakes (e.g., upcoding, unbundling) may affect MAC and payment.
Coverage and payment criteria
Administrative claim submission, documentation, coding and audit criteria that may lead to denial or recovery.
Clean Claims requirement: Providers must submit Clean Claims; Alliant may deny benefits if a Clean Claim is not submitted or required Prior Authorization approvals are not obtained.
Audit denial conditions
- Services not ordered by a physician or lacking physician order where required.
- Services not documented in the patient's medical records.
- Services routinely provided or unbundled from global charges, duplicate or already separately reimbursed charges.
- Upcoding, inappropriate professional/technical component billing, or coding inconsistent with AMA/CMS/NCCI guidelines.
Audit and recovery: Alliant may perform audits with or without records, implement coding/billing guidelines, and exercise discretion to determine coverage; Alliant may recover overpayments per contract rules.
Provider claims handling: In-Network providers typically file claims directly; Out-of-Network providers may require Members to pay and submit itemized bills for reimbursement.
Programs and exceptions: Case Management and Preventive/Wellness programs available; Alliant may require a member physical exam to adjudicate claims and will pay for it.
Complaints, grievances, and transition of care
Member complaint, grievance, transition-of-care procedures and rights when benefits are exhausted.
Transition of care after benefit exhaustion: When a Member exhausts benefits, Alliant notifies the Member and provides information about other available resources on its website in accordance with CMS/NCQA standards.
Complaints and grievances: Members may contact Client Services at (866) 403-2785 to register complaints; if unresolved, Members may file a formal complaint and request further review; summaries of grievances (three years) are available for inspection.
Complaints about provider services: If complaint involves care from a Provider, contact Client Services; Alliant will resolve in a timely manner.
Member rights: Members may expect an unbiased resolution process and have rights to appeal adverse decisions (internal and external appeal rights described separately).
Appeal process and timelines
Internal and external appeal procedures, timelines, expedited review rules, and how to request reviews.
Internal appeal process: Members or authorized representatives may file internal appeals; providers may assist or act as authorized representatives. Level I pre-service appeals decided within 15 calendar days; Level I post-service within 30 calendar days; optional Level II timelines mirror Level I.
Expedited (urgent) appeals: Expedited pre-service appeals are decided within 72 hours when application of standard timeframes could seriously jeopardize life, health, or ability to regain maximum function; providers may discuss outcomes with physician reviewers.
External review: After completing internal appeals, Members or authorized representatives may request an External review at no cost within 123 calendar days from the decision notice; expedited External reviews available in qualifying urgent circumstances; submission methods include phone, fax, or mail and medical records release may be required.
Appeal submission and documentation: Appeal requests should include member identification, denial notice date, reasons for review, and supporting evidence; Members may request copies of all documents relied upon in the adverse determination free of charge.
Covered Services criteria
Conditions required for a service to qualify as a Covered Service under the Contract.
Service must be defined as a Covered Service in the Member's Contract (Certificate and Summary of Benefits).
Service must not be specifically excluded under the Contract (see exclusions and Non-Covered Services).
Service must not be Experimental or Investigational unless it meets Alliant's Technology Assessment Criteria and evidence standards.
Service must be provided in accordance with the Contract and determined to be Medically Necessary by Alliant. When multiple clinically equivalent options exist, the least costly effective option is the Covered Service.
Covered Services are subject to Maximum Allowable Cost (MAC) and other Contract cost-sharing and limitations.
Experimental/Investigational exclusion criteria
Experimental and Investigational services are excluded unless they meet defined Technology Assessment Criteria and evidence standards.
Definition of Experimental/Investigational: Services lacking credible evidence of benefit, those in clinical trials, off-label uses without appropriate evidence, or not accepted by the majority of U.S. practitioners are considered Experimental/Investigational.
Exclusions for E/I
- The service is part of an ongoing Phase I–III clinical trial or rendered on a research basis.
- The service is not of proven benefit for the specific diagnosis or is not acceptable medical practice per AMA/FDA/NCCN/NIH standards.
- The service is an off-label use of a drug/device not supported by reliable evidence, or it fails the Technology Assessment Criteria defined by Alliant.
Administrative discretion: Alliant has full authority and discretion to interpret and determine whether a service is Experimental/Investigational to the extent permitted by law.
Administrative ineligibility criteria
Administrative ineligibility exclusions for services lacking Prior Authorization or rendered by ineligible providers or facilities.
Ineligible charge conditions
- The charges are for services that are not Medically Necessary or Prior Authorization was not obtained when required.
- Services were provided at an Ineligible Hospital (facility not meeting minimum In‑Network requirements).
- Services were provided by an Ineligible Provider (does not meet network or contracting requirements).
Ineligible services are not payable and Members/Providers should confirm network status and Prior Authorization requirements in advance.
Coverage-impacting definitions and rules
Definitions and rules that affect coverage and payment eligibility, including MAC scope and Medical Necessity determination.
Ineligible Provider rule: Services rendered by an Ineligible Provider are not eligible for payment under the Contract.
Maximum Allowed Cost (MAC): MAC applies only to Covered Services that meet Medical Necessity and Prior Authorization requirements; identifiable billing mistakes (upcoding, unbundling, duplicate charges, charges for services not performed) are excluded from MAC calculation.
Medical Necessity determination: Alliant reserves the right to determine Medical Necessity; a Provider's prescription/order alone does not establish necessity. Criteria include appropriateness to diagnosis, conformity with U.S. standards, not for convenience, not custodial care, and provided in an appropriate setting.
Late enrollee exceptions: Late Enrollee exceptions include initial enrollment, Special Enrollment events, and enrollment within 60 days after a court order for a minor Dependent.
General Medical Necessity and Prior Authorization
Overarching requirement that services be Medically Necessary and may require Prior Authorization.
All Covered Services must be Medically Necessary whether provided through In‑Network or Out‑of‑Network Providers.
Some Covered Services require Prior Authorization; Members and Providers should contact Client Services at (866) 403-2785 or AlliantPlans.com to verify Prior Authorization requirements.
Ambulance Coverage Criteria
Ambulance coverage rules for ground, air, and hospital-to-hospital transports and the medical necessity thresholds that apply.
Emergency ambulance coverage: Emergency ambulance services are Covered when Medically Necessary and criteria such as licensed vehicle/staffing and transport to an appropriate facility are met. Benefits may include medically necessary treatment during transport.
Ground ambulance (non-emergency scheduled transports): Scheduled ground ambulance services for non-emergency transports must be Medically Necessary; includes some transfers requiring skilled monitoring during transport.
Air and water ambulance: Air ambulance services (fixed wing, rotary wing, water) are subject to Medical Necessity review by Alliant; Alliant may select the air ambulance provider. Non-emergency hospital-to-hospital air transport must be Medically Necessary.
Fixed/rotary wing exceptional criteria
- Pickup point is inaccessible by land vehicle.
- Great distances, limited time frames, or other obstacles make land transport inappropriate.
- Patient's condition requires immediate rapid transport that could not be provided by land ambulance, and delay by land poses a threat to health.
Air ambulance MAC/cost sharing: For emergent out-of-network air ambulance services, the MAC is the lesser of provider billed charges or the QPA; Members pay applicable coinsurance/copayment/deductible (In‑Network cost-sharing amount applies for Out‑of‑Network emergent air ambulance services).
Anesthesia Coverage Conditions
Conditions under which general anesthesia and related facility charges for dental care are covered.
Anesthesia coverage groups
- Patient age eight or younger, or developmentally disabled.
- Local anesthesia is unlikely to produce a successful result due to a neurological disorder.
- Extensive facial or dental trauma exists (excluding Workers' Compensation claims).
- The procedure cannot be safely performed in a dental setting.
Autism Services Coverage
Autism-related diagnostic, habilitative and rehabilitative services coverage subject to Contract limitations.
Autism diagnosis and treatment coverage: The Contract provides benefits for diagnosis of Autism and for habilitative/rehabilitative services and other counseling or therapy necessary to develop, maintain, and restore functioning for individuals with Autism Spectrum Disorder (ASD), subject to Contract conditions, limitations, exclusions, and cost‑sharing.
Coverage summary and limits
Summary of notable coverage conditions, limits, and programmatic requirements across multiple benefit areas.
Assistant surgeon: Assistant surgeon services are covered when Medically Necessary and rendered in conjunction with a surgery coordinated by the Member's surgeon.
Autism services: Benefits available for diagnosis and habilitative/rehabilitative services and counseling/therapy necessary for ASD, subject to Contract provisions and cost‑sharing.
Breast cancer care and supplies: Inpatient care following mastectomy/lymph node dissection covered for an appropriate length of stay as determined by the attending Physician; follow-up visits covered; mastectomy bras covered up to 3 per calendar year.
Breast cancer screening: Annual imaging (digital mammography, tomosynthesis, x-ray, MRI) covered for women aged 40+ (or 35+ if physician‑recommended); preventive classification may apply and be provided at no cost when performed per guidelines.
Breast reconstructive care: Reconstruction following mastectomy, contralateral surgery for symmetry, prostheses, and treatment of physical complications (including lymphedema) are covered.
Clinical trial routine costs: Routine patient care costs for qualifying Members in approved clinical trials are covered if Member meets criteria and receives Prior Authorization; investigational trial treatment or trial drug costs are excluded.
Diabetes management: Coverage for diabetes equipment, supplies, medications, outpatient self‑management education, and nutritional therapy when prescribed by a physician and provided by qualified professionals.
Durable Medical Equipment (DME): DME covered if Medically Necessary, ordered by a physician, appropriate for in‑home use and meeting manufacturer/usability criteria; payment limited to rental up to the lesser of purchase price or 12 months of rental; provider must certify medical necessity and duration.
Home Health Care: Intermittent skilled care in the home covered with visits up to four hours; requires physician certification and plan of care; visit limits and plan limits outlined in the Summary of Benefits and Coverage; home health services do not reduce outpatient therapy benefit limits.
Hospice care: Inpatient and outpatient hospice services covered for patients certified by a physician as terminally ill (life expectancy ≤ 6 months); hospice program must be approved by Alliant and meet program requirements including physician direction, RN coordination, organized homecare and 24/7 availability.
Billing, MAC/QPA, and coding rules
Maximum Allowed Cost (MAC) guidancemixed
| MAC determination may adjust payments when multiple or bundled procedure codes apply; payment may be reduced for secondary procedures considered incidental or duplicate. |
Billing and coding standardsmixed
| CPT / HCPCS / ICD-10 / Revenue | Claims must be billed using accurate and appropriate CPT, HCPCS, ICD-10 and Revenue codes per AMA/CMS/NCCI guidance |
Coding and Billing Guidelinesmixed
| CPT/ICD-10/HCPCS/Revenue | Charges must be billed using accurate and appropriate CPT, ICD, HCPCS and Revenue codes; Alliant evaluates coding against AMA and CMS guidelines including NCCI and PFS. |
General coding notemixed
| Certificate of Coverage governs application of coding and billing rules; benefits subject to contract exceptions, limitations, and provisions. |
Covered Services definitionmixedCovered
| Covered Services: charges for Medically Necessary services defined in the Member's Contract that are not excluded, not Experimental or Investigational, and provided in accordance with the Contract; when options are equivalent, the least costly effective option is the Covered Service; Covered Services are subject to MAC. |
Experimental/Investigational (not covered)mixedNot Covered
| No codes listed |
Billing rules for MACmixed
| Maximum Allowed Cost (MAC) is the maximum payable amount for a Covered Service meeting Medical Necessity and Prior Authorization; MAC excludes identifiable billing mistakes including upcoding, unbundled services, duplicate charges, and charges for services not performed. |
Specialty Drugs coding notemixed
| Specialty Drugs: high-cost injectable, infused, oral or inhaled medications that typically require close supervision, special handling, and most require Prior Authorization. |
Ambulance services coding notemixed
| Emergency ambulance services are Covered when Medically Necessary; out-of-network providers may bill charges exceeding the MAC; the MAC for out-of-network emergent air ambulance is calculated as the lesser of provider billed charges or the QPA (Alliant's median contracted rate for similar services in a region). |
DME payment rulemixed
| Durable Medical Equipment payment limited to rental up to the lesser of purchase price or twelve (12) months of rental charges; DME must meet Medical Necessity and ordering/provider certification requirements. |
QPA calculation reference — No Surprises Act / median contracted rate method and alternatives
AuthorityQPA calculation follows the federal No Surprises Act methodologies
Primary methodMedian contracted rate on 1/31/2019 for same or similar service in same geographic area, adjusted for inflation
Alternative data sourcesState All-Payer Claims Database (APCD) or similar eligible third-party database
Insurer-derived fallbackAn alternate derived amount assigned by the insurer for internal accounting or data submission (45 CFR 153.710(c))
MAC computation — QPA calculation and inflation/APCD fallback
DefinitionMAC (Maximum Allowed Cost) is determined using QPA methodologies under the No Surprises Act
Computation — median rateMAC/QPA may be calculated using the median contracted rate as of 1/31/2019 adjusted for inflation
APCD fallbackState All-Payer Claims Database amounts may be used where applicable
Alternate derived amountInsurer-assigned alternate derived amount may be used for internal accounting or data submission
Provider recovery window — 12 months recovery period for erroneous payments (except fraud)
Recovery windowWe may recover payments made in error from the Provider within 12 months after the payment date (except in cases of fraud)
ScopeRight to recover overpayments applies to payments made in error to Providers or Members
OffsetWe may deduct or offset amounts paid in error from any pending or future claim
Misc code key
NoteNo misc code summary content provided in the brief or source document
ActionNo codes to display; refer to coding tables and MAC/Billing rules sections for relevant coding guidance
Source guidanceSee Coding and Billing sections for applicable CPT/HCPCS/ICD-10 requirements
deductible_application_period — calendar year
Application periodDeductible is applied on a calendar year basis (January 1–December 31)
EffectivityDeductible does not begin before a Member's Effective Date and does not continue after coverage ends
ReferenceSee Deductible definition and Benefit/Contract Year provisions
Infertility definition timeframe — 1 year required
TimeframeInfertility defined as inability to conceive after one year of frequent, unprotected heterosexual vaginal intercourse
ExclusionsExcludes infertility due to vasectomy, orchiectomy, tubal ligation, or hysterectomy
ApplicabilityDefinition applies to determination of infertility-related benefits under the Contract
Out-of-Network air ambulance MAC calculation — MAC is lesser of billed charges or QPA
MAC rule for OON air ambulanceFor Out-of-Network emergent air ambulance services, MAC is the lesser of the provider's billed charges or the QPA
QPA definitionQPA is Alliant's median contracted rate for similar services in a specific geographic region
Member cost-shareAmbulance providers may bill You for coinsurance, copayment, or deductible per Your policy; In-Network cost-sharing applies to emergent air ambulance services
Hearing aid frequency and dollar limit (children) — one hearing aid per ear ≤ $1,000 every 36 months
Frequency and limitFor members under age 18: one hearing aid per hearing‑impaired ear every 36 months, not to exceed $1,000 per device
Included itemsCoverage includes nonexperimental wearable hearing instruments, parts, ear molds, repair and replacement parts
Exclusions/notesPersonal sound amplification products do not qualify as hearing aids; benefits subject to Contract conditions and Summary of Benefits limits
Prior authorization, documentation, and provider responsibilities
Prior Authorization
In‑Network Prior Authorization — Provider must call Alliant Medical Management
Your In‑Network Provider or Hospital should contact Alliant Medical Management for prior authorization before administering services or admitting the patient; Members are responsible for obtaining any necessary prior authorization when using an Out‑of‑Network provider.
- Alliant Medical Management phone: (800) 865-5922
Prior Authorization
In‑Network Provider Prior Authorization Procedure
For prior authorization of in‑network services or inpatient admissions (except maternity), the Provider must call Alliant Medical Management at (800) 865-5922; the Provider should notify Alliant by the next business day for emergency or maternity admissions. Providers may request non‑urgent authorizations during normal business hours. Emergency Medical Services do not require prior authorization.
- Provider phone for prior auth: (800) 865-5922
- Notify Alliant by next business day for emergency or maternity admissions
- Emergency services do NOT require prior authorization
Prior Authorization
Prior Authorization Contact — call (800) 865-5922
If a verified service requires prior authorization, call (800) 865-5922 to obtain authorization — verification of benefits alone is not confirmation of coverage or payment.
- Verification of benefits is NOT a guarantee of payment
- If prior authorization is required, call (800) 865-5922
Prior Authorization
In‑Network Inpatient Admission — Provider call required
Providers must call (800) 865-5922 for prior authorization for all in‑patient in‑network admissions (except maternity); providers should notify Alliant by the next business day of emergency or maternity admissions and may request non‑urgent authorizations during normal business hours.
- Provider prior authorization number: (800) 865-5922
- Required for ALL in‑patient in‑network admissions except maternity
- Notify by next business day for emergency or maternity admissions
Prior Authorization
Out‑of‑Network Prior Authorization — Member must call
For out‑of‑network inpatient admissions or PHCS Network admissions, the MEMBER (YOU) must call Alliant at (800) 865-5922 to obtain prior authorization; the Member must notify Alliant within 1 business day of an emergency or maternity admission or the claim may be denied.
- Member prior authorization phone: (800) 865-5922
- YOU must notify Alliant within 1 business day of emergency or maternity admission or claim may be denied
Denial Risk
Prior Authorization Is Not a Guarantee of Coverage
Prior authorization is not a guarantee of coverage in specified situations — e.g., if the Member is not covered at time of service, benefits are exhausted, fraud/misrepresentation, or the service is not a Covered Service; approvals apply only to services listed in the request and do not extend to other services or guarantee future claim payment.
- Prior Authorization approvals apply only to services outlined in the request or listed on AlliantPlans.com
- Approval for one service does not extend to other services
- Authorization is not coverage guarantee if coverage ended, benefits exhausted, fraud/misrepresentation, or service not covered
Prior Authorization
Authorization Types & Decision Timeframes
Authorizations are granted based on Medical Necessity. Timeframes: urgent (as soon as possible, ≤72 hours); pre‑service (within 7 calendar days, may extend 7 more days); concurrent (within 24 hours for urgent requests, otherwise within 7 days); post‑service review (decision within 30 calendar days).
- Authorizations are based on Medical Necessity
- Urgent authorization decision timeframe: no more than 72 hours
- Pre‑service authorization decision timeframe: within 7 calendar days (may extend 7 more)
- Post‑service review decision timeframe: within 30 calendar days
Documentation Required
Benefit Verification Is Not a Payment Guarantee
Verification of benefits by Client Services does not confirm coverage or guarantee payment for a specific procedure; if prior authorization is required after verification, call (800) 865-5922 to obtain it.
- Benefit verification is NOT a guarantee of payment
- If verification indicates prior authorization is required, call (800) 865-5922
Prior Authorization
Authorized Services for Out‑of‑Network Providers — request in advance
When no in‑network provider is available for a Covered Service, the Member may contact Alliant in advance to authorize applying in‑network cost‑share amounts to an out‑of‑network provider; such authorization does not guarantee Alliant will cover amounts above the MAC and the Member may be liable for the difference.
- Contact Client Services at (866) 403-2785 to request Authorized Services
- Authorization may apply In‑Network deductible/copay/coinsurance but Member may still owe difference between provider charge and MAC
Documentation Required
Medical Bill Review — Clean Claims and Records Required
Alliant may request and review medical records as part of medical bill review; providers must submit Clean Claims and required prior authorization approvals, and provide complete itemization and medical records upon request — failure to do so may result in no benefits payable.
- Providers must submit Clean Claims
- Alliant reserves the right to request medical records and complete itemizations
- Failure to submit Clean Claims or required prior authorizations can make benefits non‑payable
Denial Risk
Audit‑Based Denial Risks — documentation, ordering, coding
Alliant may deny payment identified during audits for services that were not ordered by a physician, not documented in medical records, routine/unbundled, upcoded, or otherwise non‑covered under the Contract.
- Services not ordered by a physician or not documented may be denied
- Routine/unbundled services, upcoded services, or services considered Non‑Covered may be denied
- Alliant uses audits and claim review rules to determine denials
Documentation Required
Provider Role in Appeals & Submission Contacts
Providers may assist or act as an authorized representative for members in appeals; medical and pharmacy prior authorization appeals have specific submission addresses, phone numbers, and fax numbers — see appeal instructions for mailing/fax contacts and timelines.
- Medical prior authorization appeals: Alliant Health Plans Appeals Dept, PO Box 1247 Dalton, GA 30722; Phone: (800) 865-5922; Fax: (866) 634-8917
- Pharmacy appeals: Prime Therapeutics contact details provided (phone/fax)
Documentation Required
Provider Right to Discuss Appeal Outcomes
Providers have the right to discuss appeal outcomes with a physician or appropriate reviewer; appeal notices will list the specific reasons for the decision and the individuals involved in decision making.
- Appeal notice includes reasons and decision makers
- Provider may discuss outcome with a physician or other appropriate reviewer
Note
External Review Request Procedure — 123‑day filing window
Members or their authorized representatives may request an External review at no cost within 123 calendar days from the date of the adverse decision notice; requests may be submitted by calling Alliant toll‑free, fax, or mail as specified.
- External review request options: call (800) 865-5922, fax (866) 634-8917, or mail to Alliant Health Plans Appeals Dept PO Box 1247 Dalton, GA 30722
- External review must be filed within 123 calendar days of decision notice
Note
Direct Access — members may see primary & specialty physicians without referral
Members have direct access to primary and specialty physicians without need for an Alliant‑approved referral.
- Direct Access means no Alliant referral required for primary or specialty care
Prior Authorization
Prior Authorization Requirement — charges without prior auth are ineligible
Prior authorization is required for certain services; charges for services provided without required prior authorization are Ineligible Charges and not eligible for payment.
- Charges lacking required prior authorization are not eligible for payment
- Prior authorization requirement applies to services listed on AlliantPlans.com or Client Services
Billing Rule
MAC Applies Only When Medical Necessity and Prior Authorization Are Met
The MAC (Maximum Allowed Cost) applies only to Covered Services that meet Medical Necessity and prior authorization requirements; the MAC excludes identifiable billing mistakes such as upcoding, unbundled or duplicate charges, and charges for services not performed.
- MAC applies only to services meeting Medical Necessity and Prior Authorization
- Identifiable billing mistakes are excluded from MAC (e.g., upcoding, unbundled services, duplicate charges)
Prior Authorization
Medical Necessity Determination — Alliant has final authority
Alliant reserves the right to determine Medical Necessity; a Physician's prescription, order, or recommendation alone does not establish Medical Necessity — services must meet Alliant's criteria (appropriate, consistent with diagnosis, compatible with U.S. standards, not custodial, provided in appropriate setting).
- Alliant determines Medical Necessity
- Physician order alone does not guarantee coverage
Prior Authorization
Pharmacy Prior Authorization — formulary may require prior auth
The Outpatient Prescription Drug Formulary may include prior authorization rules and is periodically reviewed and modified by Alliant; medications selected outside the formulary may be Ineligible Charges.
- Formulary may list drugs requiring prior authorization
- Charges may be ineligible if Member selects drug not in formulary
Prior Authorization
Prior Authorization Definition & Specialty Drug Note
Prior Authorization is the process Alliant uses to determine whether a procedure or treatment is medically necessary and covered; approvals are subject to plan limits and exclusions, and specialty drugs typically require prior authorization.
- Prior Authorization determines medical necessity and coverage eligibility
- Most Specialty Drugs require Prior Authorization
Prior Authorization
Prior Authorization Notification — confirm via Client Services or website
Some Covered Services may require prior authorization; Members and providers may contact Client Services at (866) 403-2785 or visit AlliantPlans.com to confirm whether a specific benefit requires prior authorization.
- Client Services: (866) 403-2785
- Prior Authorization list is available on AlliantPlans.com and is subject to change
Documentation Required
Ambulance Medical Necessity Review & Provider Selection
Ground and air ambulance services are subject to Alliant medical necessity review; Alliant may select the air ambulance provider for transport, and scheduled/non‑emergency ground or air transports must be medically necessary.
- Ground ambulance and scheduled non‑emergency transports require medical necessity review
- Alliant may select air ambulance provider for air/water transports
Prior Authorization
Clinical Trial Prior Authorization Required for Routine Trial Costs
Alliant requires prior authorization for routine patient care costs related to participation in qualifying clinical trials; to qualify Members must be enrolled, meet trial criteria, be referred by an in‑network provider, and receive prior authorization from Alliant.
- Clinical trial routine patient costs require Alliant prior authorization
- Member must be referred by an In‑Network Provider and accepted into an approved trial
Key terms used in the Certificate
We/Us/Our, You/Your — Alliant and Member term mapping
Plan identity"We," "Us," and "Our" refer to Alliant Health Plans
Member identity"You" and "Your" refer to the Member — the Subscriber and any covered Dependents
Document contextTerms used consistently throughout this Certificate of Coverage
Subscriber or Member definition
DefinitionSubscriber or Member: the individual who signed the Application for Enrollment and in whose name the Identification Card is issued
RoleSubscriber/Member is covered under the Group Health Care Contract and may enroll eligible Dependents
EnrollmentSubscriber or Plan Administrator must notify Alliant by completing an enrollment application to add Dependents
Eligible Dependents — spouse, children through end of month they turn 26, adopted/foster rules
Eligible dependents — spouseSpouse is eligible if You are not legally separated
Eligible dependents — childrenDependent children are eligible through the end of the month in which they attain age 26
Adopted/foster rulesLegally adopted children are eligible from date You assume legal responsibility; foster children qualifying under specified conditions may be eligible; certification and timing rules apply
Total disability definition references
General referenceTotal disability is referenced in extension of benefits and termination provisions
Extension contextIf a Subscriber is totally disabled when Group Contract terminates, benefits for the disabling condition may be extended up to 12 months
Related rulesExtension applies only to Covered Services due to the disabling condition and ends at specified triggers (end of disability, one year after coverage ends, or payment limit reached)
Total disability detailed definition — inability to perform occupation duties or normal activities
Core definitionTotal disability: Member unable to perform major duties of occupation and unable to work for wages or profit; for Dependents, inability to engage in most normal activities for their age and sex
Use in policyUsed to determine eligibility for extended benefits after Group Contract termination
CertificationPhysician care and certification are required for benefit extensions tied to total disability
In-Network Provider definition
DefinitionAn In‑Network Provider is a healthcare provider who is part of Our network or has a contract with Alliant Health Plans and has agreed to contracted reimbursement rates
ImplicationUsing an In‑Network Provider generally results in lower out‑of‑pocket costs for Members
DirectoryFor a list of In‑Network Providers visit AlliantPlans.com or call Client Services (866) 403‑2785
Maximum Allowed Cost (MAC) / QPA definition
MAC/QPA purposeMaximum Allowed Cost (MAC) / Qualifying Payment Amount (QPA) is the amount used to determine reimbursement for Covered Services meeting Medical Necessity and Prior Authorization requirements
Calculation basisQPA is calculated per the No Surprises Act methodologies (median contracted rate 1/31/2019 adjusted for inflation, APCD, or insurer-derived amount)
ExclusionsMAC does not include identifiable billing mistakes such as upcoding, unbundled or duplicate charges, or charges for services not performed
MAC term
TermMAC means Maximum Allowed Cost or Maximum Allowable Charge — the maximum amount payable for a Covered Service under the Contract meeting Medical Necessity and Prior Authorization requirements
LimitationsMAC excludes identifiable billing mistakes (upcoding, unbundled services, duplicate charges, charges for services not performed)
ApplicationMAC applies to Covered Services and is used to determine plan payment and Member cost‑share
QPA term definition
DefinitionQPA (Qualifying Payment Amount) is the amount calculated under the federal No Surprises Act methodologies used in MAC determination for emergency and certain surprise billing situations
MethodsQPA methods include median contracted rate (1/31/2019) adjusted for inflation, APCD data, or insurer-derived alternate amount
RoleQPA serves as the basis for computing MAC and certain Out‑of‑Network payment protections
Balance billing definition and prohibition guidance
Balance billing definedBalance billing occurs when a provider bills a Member for amounts in excess of the allowed amount (MAC)
Prohibition for INNIn‑Network Providers are prohibited from balance billing Members for Covered Services (Member liable only for contract cost‑share)
OON guidanceOut‑of‑Network Providers may bill amounts above the MAC subject to surprise billing protections; non‑Covered Services remain Member's responsibility
Medicare coordination (MSP) reference
ReferenceMedicare coordination is governed by Medicare Secondary Payer laws and federal regulations
EffectWhen benefits are payable under both this Certificate and Medicare, payments will be made pursuant to Medicare rules; federal law controls in conflicts
ReimbursementWhere Medicare is primary, Alliant seeks reimbursement of sums payable by Medicare to the extent Alliant has paid
Recovery and Subrogation definition
DefinitionRecovery and Subrogation: Alliant's rights to recover overpayments and to be reimbursed or subrogated from third‑party recoveries for which benefits were paid
Member obligationsYou must inform Alliant of legal action or settlement discussions and cooperate; Alliant has first right to reimbursement from recoveries
ScopeRight of recovery limited to amounts paid for covered medical expenses; Alliant may pursue recoveries, compromise settlements, and retain recoveries per policy
Adverse Benefit Determination definition
DefinitionAdverse Benefit Determination: a denial or failure to provide or make payment (in whole or in part), reductions or terminations, or determinations based on medical judgment
IncludesRescissions and retroactive cancellations (except for non‑payment of premiums) and decisions to deny coverage as not Medically Necessary, experimental, cosmetic, or inappropriate
Use in appealsTriggers internal and external appeal rights as described in the appeals section
Authorized Representative definition
DefinitionAuthorized Representative: an individual authorized in writing by the Member or by state law to act on the Member's behalf for services, claims or appeals
Provider exceptionA health care provider may act without express consent for Urgent Care Services
ScopeApplies to requests for services, claim payments, and internal appeal processes
Final Adverse Benefit Determination definition
DefinitionFinal Adverse Benefit Determination: an Adverse Benefit Determination that is upheld after internal appeal; if internal appeal timeframe elapses without determination, it is deemed Final
Appeal implicationA Final Adverse Benefit Determination permits request for External Review within specified timelines
Timing noteIf internal appeal timeframes lapse without decision, deemed final by operation of policy
Post-Service Claim definition
DefinitionPost‑Service Claim: an Adverse Benefit Determination rendered for a service that has already been provided
ProcessSubject to post‑service internal appeal timelines and potential external review eligibility
DistinctionDiffers from Pre‑Service and Urgent Care claims due to service already rendered
Pre-Service Claim definition
DefinitionPre‑Service Claim: an Adverse Benefit Determination where the requested service has not been provided
UseTriggers pre‑service internal appeal procedures and timelines
Relation to prior authorizationOften arises from denial of prior authorization requests
Urgent Care Services Claim definition
DefinitionUrgent Care Services Claim: an Adverse Benefit Determination for a request where applying non‑urgent timeframes could seriously jeopardize life, health, or cause severe unmanaged pain
StandardTreatment urgency judged by treating physician and circumstances that could endanger life or health
Appeal timeframesSubject to expedited (urgent) appeal procedures per policy timelines
Accidental Injury definition
DefinitionAccidental Injury: bodily injury sustained by a Member as the result of an unforeseen event and which is the direct cause for care received
ExclusionDoes not include injuries covered by Workers' Compensation or similar laws
UseRelevant for claims where cause affects coverage or coordination of benefits
After-Hours Office Visit definition
DefinitionAfter‑Hours Office Visit: care rendered as a result of a condition that has onset after the Physician's business hours
SettingDistinguished from routine visits and may affect benefit application per Contract
Provider notePhysicians' offices do not qualify as Ambulatory Facilities for certain definitions
Ambulatory Facility definition
DefinitionAmbulatory Facility: licensed facility where outpatient surgical procedures are performed with no overnight stays and staffed by Physicians and R.N.s
ExclusionA Physician's office does not qualify as an Ambulatory Facility
LicensureMust be licensed by appropriate state agency
Applicant definition
DefinitionApplicant: the individual who applied for this Contract
UseTerm used in enrollment and eligibility provisions
Related docApplication for Enrollment records support Applicant status
Application for Enrollment definition
DefinitionApplication for Enrollment: the original and any subsequent forms completed and signed by the Subscriber seeking coverage (may be electronic)
PurposeUsed to enroll Subscribers and Dependents and to establish coverage under the Contract
RecordkeepingPlan Administrator maintains enrollment records as part of the Group Health Care Contract
Autism definition
DefinitionAutism: a developmental neurological disorder usually appearing in the first three years of life with compulsive, ritualistic behavior and impaired social interaction and communication
Coverage noteContract provides benefits for diagnosis and habilitative/rehabilitative services for ASD subject to Contract limits
ScopeBenefits follow conditions, limitations, exclusions, cost‑sharing in the Contract
Benefit Period definition — Jan 1–Dec 31
DefinitionBenefit Period: one year, January 1 – December 31 (calendar year)
EffectDoes not begin before a Member's Effective Date and does not continue after coverage ends
Relation to Contract YearContract Year and Benefit Period align to calendar year per Contract definitions
Brand Name Drugs definition
DefinitionBrand Name Drugs: drugs under patent by original innovator/marketer; single‑source have no generic equivalent, multi‑source have generics
ImplicationFormulary and coverage may distinguish Brand Name vs. generic for cost‑sharing and prior authorization
RelatedSee Outpatient Prescription Drug Formulary for prior authorization rules
Certificate; Chemical Dependency Treatment Facility definition
DefinitionCertificate: a short written statement defining Our legal obligation to Members; Chemical Dependency Treatment Facility defined with licensure/accreditation requirements
Facility standardsChemical Dependency Treatment Facilities must be licensed by state authority or accredited by Joint Commission
Contract contextThe Certificate together with the Alliant Formulary and Application constitute the Contract
Clean Claim definition
DefinitionClean Claim: a claim submitted in a nationally accepted format that requires no further information, adjustment, or alteration to be processed and paid
Provider obligationProviders are required to submit Clean Claims; failure may lead to denial or delay
ProcessingClean Claims comply with standard coding guidelines (CPT/HCPCS/ICD‑10) as required
Coinsurance definition
DefinitionCoinsurance: the portion of covered charges a Member is responsible for when benefits cover a percentage (e.g., remaining 20% when coverage is 80%)
Relation to OOPCoinsurance may be capped by the Out‑of‑Pocket Maximum
DistinctionCoinsurance is distinct from Copayment (flat dollar amount)
Combined Limit definition
DefinitionCombined Limit: the maximum total of In‑Network and Out‑of‑Network care available for designated services in the Summary of Benefits and Coverage
ApplicationCombined limits may restrict amounts available for certain services across network types
ReferenceSee Summary of Benefits and Coverage for plan‑specific limits
Complications of Pregnancy definition
DefinitionComplications of Pregnancy: conditions distinct from pregnancy that require hospital confinement and are adversely affected by pregnancy
ExamplesIncludes preeclampsia, intrauterine growth retardation, ectopic pregnancy; excludes routine pregnancy management
Coverage implicationSuch complications are treated as Covered Services when meeting Medical Necessity criteria
Congenital/developmental Anomaly definition
DefinitionCongenital/developmental Anomaly: a condition present at birth regardless of causation; may be hereditary or due to gestational influence
Coverage noteSubject to Contract conditions and exclusions
UseTerm used in determining eligibility for certain pediatric services and interventions
Contract definition
Contract definitionThe Certificate, the Alliant Formulary, amendments or riders, and the Application for Enrollment constitute the entire Contract
HierarchyAmendments or riders control in conflicts with the Certificate
AccessGroup Health Care Contract may be inspected at the Plan Administrator's office
Contract Year definition — Jan 1–Dec 31
DefinitionContract Year: one calendar year commencing January 1 at 12:01 am and ending December 31 at 11:59 pm Eastern Time
AlignmentContract Year aligns with Benefit Period/calendar year provisions
UseApplies to plan-year measures such as deductibles and out‑of‑pocket maxima
Coordination of Benefits definition
DefinitionCoordination of Benefits: provision to avoid payment delays and duplicate benefits when covered by multiple plans by establishing order of payment and information transfer rules
EffectMay reduce benefits if not primary payer and governs interactions with other coverage sources
ProcedureOrder of benefit determination rules and reporting requirements apply per Contract
Copayment definition
DefinitionCopayment: a flat dollar cost‑share a Member pays for a Covered Service, usually at time of service
DistinctionCopayment is distinct from Coinsurance which is percentage‑based
CollectionCopayments may be collected by the Provider at time of service
Cosmetic Surgery definition
DefinitionCosmetic Surgery: non‑Medically Necessary procedures primarily to improve appearance and not to restore function or correct disease/defect
ExamplesIncludes rhinoplasty, lipectomy, mammoplasty, liposuction and related procedures
CoverageTypically excluded unless medically necessary per Contract definitions
Covered Dependent definition
DefinitionCovered Dependent: a Dependent who meets Eligibility requirements, has enrolled, and complied with Premium requirements
Age ruleDependent coverage typically ends at the end of the month in which the Dependent attains age 26 unless disabled and certified
EnrollmentDependent must be reported and added via correct enrollment application
Covered Services definition
DefinitionCovered Services: Medically Necessary services, not excluded or Experimental/Investigational, and provided in accordance with the Contract
Least‑cost ruleWhen multiple equally effective options exist, the least costly no‑less‑effective option is the Covered Service
Subject to MACCovered Services are subject to the Maximum Allowed Cost and Contract exclusions when determining plan payment
Creditable Coverage definition — 90-day gap rule
DefinitionCreditable Coverage: other medical expense coverage with no greater than a 90‑day gap under specified programs (Medicare/Medicaid, employer‑based, individual, spouse coverage, conversion policy) or as defined by Tennessee law
Portability implicationMay enable HIPAA portability and affect special enrollment rights
DocumentationMembers may request certification of prior creditable coverage
Custodial Care definition
DefinitionCustodial Care: care that does not require skilled professional/technical personnel or supervision and is at a level where no further significant improvement is likely
ExclusionTypically excluded from Covered Services definition as not Medically Necessary
ExamplesRoom and board, personal care and assistance not requiring medical skill
Deductible definition — calendar year application
DefinitionDeductible: the portion of the bill the Member must pay before medical expenses become reimbursable; applied on a calendar year basis
TimingDeductible does not begin before Member's Effective Date and does not continue after coverage ends
ReferenceSee Summary of Benefits and Coverage for plan‑specific Deductible amounts
Dependent definition — spouse and children to 26, with details
DefinitionDependent: spouse and children until attaining age 26; includes natural, legally adopted, stepchildren, certain foster children and children under court decree
Disabled dependent ruleChildren who are mentally or physically disabled and totally dependent may remain covered regardless of age with required certification
Age cutoff detailCoverage through end of month in which dependent attains age 26
Detoxification definition
DefinitionDetoxification: licensed facility process to eliminate intoxicants under physician determination while minimizing physiological risk
SettingProvided in licensed facilities per Contract requirements
CoverageSubject to Medical Necessity and Contract conditions
Developmental Delay definition
DefinitionDevelopmental Delay: statistical variation in reaching age‑appropriate milestones as defined by validated screening tests; not by itself an illness
Coverage implicationServices should target specific functional deficits identified and meet Medical Necessity
AssessmentDetermination based on standardized developmental screening tools
Direct Access definition
DefinitionDirect Access: Member access to primary and specialty care Physicians without the need for an Alliant‑approved referral
ImplicationMembers may seek specialty care directly where plan design allows
RelationDoes not remove Prior Authorization requirements where specified
Durable Medical Equipment definition
DefinitionDurable Medical Equipment (DME): equipment determined by Alliant to withstand prolonged use, mainly used in treatment, suitable for home use, and not for exercise/training
Payment rulePayment limited to rental up to the lesser of purchase price or 12 months of rental (see DME payment rules)
RequirementDME must be ordered by a physician and certified as medically necessary
Effective Date definition
DefinitionEffective Date: the date on which benefits begin for each Member
Enrollment linkCoverage effective date may be subject to employer waiting period and active work requirements
ImpactBenefit Period and Contract Year do not begin before the Member's Effective Date
Elective Surgical Procedure definition
DefinitionElective Surgical Procedure: a non‑emergency surgical procedure that may be scheduled or delayed
Coverage noteSubject to Medical Necessity and Prior Authorization where required
DistinctionDifferent from emergency procedures which are covered when Medically Necessary
Emergency Medical Services definition
DefinitionEmergency Medical Services: acute symptoms of sufficient severity that a prudent layperson could expect lack of immediate attention to result in serious jeopardy to health, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part
Member actionIf emergency care is required, go to the emergency room or call 911; ER copayment may be waived if admitted
Balance billing protectionMembers cannot be balance‑billed for Out‑of‑Network emergency services under state and federal surprise billing laws
Plan Administrator definition
DefinitionPlan Administrator: the person named by Your employer to manage the plan and answer questions about plan details
RoleActs as employer agent for enrollment, notices, and Plan interactions with Alliant
ContactPlan Administrator maintains Group Health Care Contract and enrollment records
Policies and Procedures definition
DefinitionPolicies and Procedures: Alliant's medical, payment, claims processing and administrative policies that govern benefit determinations and may be revised periodically
NaturePolicies are not authorizations or contracts for payment; benefits determined by Contract at time services rendered
UpdatesAlliant reserves right to review and revise Policies periodically based on medical literature and practice
PPACA acronym definition
DefinitionPPACA: Patient Protection and Affordable Care Act
ContextReferences federal Essential Health Benefits requirements within the Contract
UseAppears in definitions related to required benefit categories
PPO Network / PPO Network Provider definition
PPO NetworkA Preferred Provider Organization (PPO) is a limited panel of Providers as designated by Alliant
PPO Network ProviderA Provider included in Alliant's limited panel for which the greatest benefit will be payable when used
Member impactUsing PPO Network Providers yields higher benefit levels per plan design
Premium and Prescription Drug definitions
PremiumThe amount that the Group or Member is required to pay for coverage
Prescription DrugA drug that can only be purchased with a Physician's prescription and must be dispensed by a pharmacist
Plan financePremiums are collected by Group/Plan Administrator per enrollment and payment rules
Primary Care Physician (PCP) definition
DefinitionPrimary Care Physician (PCP): licensed family practice, general practice, pediatrics, OB/GYN or internal medicine Physician who coordinates Member care
RolePCP coordinates care and may provide referrals where required by plan design
NetworkPCP selection may affect access to In‑Network benefits and care coordination
Hearing Aid definition (children) reference
Hearing AidHearing Aid: nonexperimental wearable instrument to aid hearing including parts, ear molds, repair and replacement parts; personal sound amplification products excluded
Child limitFor children under 18, one hearing aid per hearing‑impaired ear every 36 months up to $1,000 per device
Coverage conditionsBenefits provided per Contract conditions, limitations, exclusions, and cost‑sharing in the Summary of Benefits
Provider definition
DefinitionProvider: any Physician, health care practitioner, pharmacy, supplier or facility holding required licenses to provide health care services
ScopeIncludes Hospitals, labs, ASCs, Retail Health Clinics, SNFs, LTACs, Home Health Agencies
Network statusProvider may be In‑Network or Out‑of‑Network depending on contractual relationship with Alliant
Reasonable and/or Reasonableness definition
DefinitionReasonable and/or Reasonableness: services or supplies that Alliant determines are necessary for care and treatment, considering industry standards and evidence
DiscretionAlliant has discretionary authority to determine Reasonableness based on presented information and guidelines
ExclusionsServices resulting from preventable provider errors or not following evidence‑based guidelines may be deemed not Reasonable
Referral definition
DefinitionReferral: specific instructions from a Member's Physician directing the Member to an In‑Network Provider for Medically Necessary care
UseReferrals conform to Alliant policies and procedures and may be required for certain plan designs
RelationDirect Access may allow some specialty visits without referrals depending on plan terms
Respite Care definition
DefinitionRespite Care: care furnished during a period when the Member's family or usual caretaker cannot or will not attend to the Member's needs
ScopeMay be covered subject to Medical Necessity and Contract conditions
SettingOften provided in home or facility settings as short‑term relief for caregivers
Retail Health Clinic definition
DefinitionRetail Health Clinic: facility providing limited basic medical care on a walk‑in basis, often located in pharmacies or retail stores
ProvidersServices typically provided by Physician Assistants and Nurse Practitioners
CoverageServices are subject to plan coverage rules and Medical Necessity determinations
Semiprivate Room definition
DefinitionSemiprivate Room: a Hospital room which contains two or more beds
BillingRoom type may affect Covered Services and facility charges as determined by Medical Necessity
Facility standardsHospitals must meet state licensure and staffing requirements to qualify for coverage
Service Area definition
DefinitionService Area: specific geographic areas (such as counties) where coverage is offered
Plan effectMembers' eligibility and provider networks may vary by Service Area
ReferenceSee Plan Administrator and Group enrollment documents for service area details
Skilled Convalescent Care definition
DefinitionSkilled Convalescent Care: care received in a Skilled Nursing Facility while recovering from illness or Injury requiring more care than at home but less than a Hospital
LicensureFacility must be state‑licensed and meet accreditation/Alliant standards
CoverageBenefits determined by Medical Necessity and Contract terms
Skilled Nursing Facility definition
DefinitionSkilled Nursing Facility: an institution providing care after hospital discharge for conditions requiring more care than can be given at home
StandardsMust be licensed by state agency and accredited or meet Alliant's reasonable standards
Coverage limitsSubject to Contract and Summary of Benefits visit/length limits
Specialty Drugs definition
DefinitionSpecialty Drugs: high‑cost injectable, infused, oral or inhaled medications requiring close supervision, special handling, and often prior authorization
Prior AuthorizationMost Specialty Drugs require Prior Authorization per the Outpatient Prescription Drug Formulary
DistributionOften dispensed via Specialty Pharmacy rather than retail pharmacies
Specialty Pharmacy definition
DefinitionSpecialty Pharmacy: pharmacy dispensing biotech drugs for rare/chronic diseases via scheduled delivery and providing telephonic therapy management
RoleSupports safe administration and compliance for Specialty Drugs
ChannelMay be required for coverage of certain high‑cost or limited‑distribution drugs
Spinal Manipulation definition
DefinitionSpinal Manipulation: correction of subluxations to remove nerve interference related to distortion or misalignment of the vertebral column
CoverageMay be covered subject to Medical Necessity and plan visit limits/cost sharing
CodingSubject to coding and bundle rules under Alliant's Payment Policies
Subscriber definition
DefinitionSubscriber: the individual who signed the Application for Enrollment and in whose name the Identification Card is issued
RelationSubscriber is the primary policyholder and may enroll eligible Dependents
ResponsibilitiesSubscriber/Plan Administrator must notify Alliant of enrollment changes per Contract rules
Substance Abuse; Substance Abuse Rehabilitation definitions
Substance AbuseAny use of alcohol and/or drugs producing patterns of pathological use causing impairment in functioning or physiological dependency
Substance Abuse RehabilitationServices and interventions to eliminate dependence on or abuse of chemical substances per individual treatment plans
SettingsIncludes residential treatment centers and hospital‑based services subject to Contract criteria
Technology Assessment Criteria — five criteria for coverage
Technology Assessment CriteriaFive criteria that procedures must meet to be Covered Services: regulatory approval; evidence permits conclusions on health outcomes; improves net health outcome; as beneficial as alternatives; beneficial in practice
ApplicationExperimental/Investigational services must meet these criteria to be considered Covered
DiscretionAlliant has authority to interpret and apply the Technology Assessment Criteria
Telehealth / Telemedicine definitions
Telehealth ServicesUse of information and communication technologies (phones, remote monitoring, electronic means) supporting clinical health care, consultation, education and health administration
TelemedicineDelivery of clinical health care services via real‑time two‑way audio/visual or other electronic communications by a licensed provider practicing within scope and legally allowed in the state
Patient/provider locationsPatient at originating site and provider at distant site; practice consistent with in‑person standards
Timeframes, contact numbers, and operational limits
72urgent auth hours
7pre-service auth days
30post-service review days
180claims submission days
Provider and member contacts for prior auth and case management
Provider prior authorization contactProviders must call Alliant Medical Management for Prior Authorization at (800) 865‑5922
Member contactMembers or authorized providers can verify benefits via Client Services at (866) 403‑2785; verification is not a guarantee of payment
Nurse Advice LineNurse Advice Line 24‑hour availability noted on the Alliant website (AlliantPlans.com)
QPA/MAC calculation references and No Surprises Act fallback methods
QPA / MAC methodsQPA calculated per No Surprises Act using median contracted rate (1/31/2019) adjusted for inflation; APCD or insurer‑derived alternate may be used
ApplicationUsed for emergency services and surprise billing MAC computations
DocumentationAlliant may request provider documentation to confirm circumstances for surprise billing determinations
Provider repayment recovery window — 12 months (except fraud)
Provider repayment windowAlliant will recover payments made in error from a Provider within 12 months after the payment date, except in cases of fraud
ExceptionsFraud cases are not bound by the 12‑month recovery limitation
Offset and cooperationAlliant may offset amounts against future claims and Members/Providers must cooperate with recovery and subrogation actions
Document updates and timeline
Effective 2025-01-01privacy_notice_effective_date
Notice of Privacy Practices became effective on 1/1/2025 per the document's privacy section.
2026certificate_issue_yearLatest
This Certificate of Coverage is titled for the 2026 SimpleCare Group Health Plan and replaces previous certificates.
Policy Summary
PayerAlliant Health
PolicyCertificate of Coverage (Group Health Plan)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionYour in‑network provider or hospital should call Alliant Medical Management for Prior Authorization before services or admission; members must call for out‑of‑network admissions at (800) 865-5922.
SourceLink
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