Alliance makes every effort to first link consumers with Network Providers, but will consider enrolling an Out-of-Network Provider if a Network Provider is not available or accessible to the enrollee.

The Out-of-Network Provider will submit a Provider Application Request, which will collect information about the provider type, specialties, services requesting to provide, location and information regarding the consumer. Please include any specialty or pertinent information related to request for review and submit the Request to ProviderNetwork@AllianceBHC.org .

Geo-mapping will be completed and Provider Network staff will review the information and will identify if there is a Network gap or if there is a Network Provider who meets the thirty (30) mile radius requirement and can provide the approved service. If there was no consumer identified in the request the Provider will be informed that at this time the Network is closed and based on a review of provider type and location that we are unable to move forward with the application process. If there was a consumer identified the Provider will be informed that at this time our Network is closed and based on a review of provider type Alliance has current providers available to serve the consumer(s) and a list of contracted providers with contact information will be sent to the provider within seven (7) calendar days.

Out-of-Network Single Client Application/Agreement

If there are no Network Providers who can provide the approved service within the thirty (30) mile radius and the treatment is client specific and temporary, a ninety (90) day Out-of-Network Single Client Application/Agreement will be pursued:

  1. Provider will be notified they are approved to submit an Out of Network SAR to determine Medical Necessity.
  2.  The Provider will complete and return the Out-of-Network SAR (to fax number indicated on SAR) within two weeks of receiving the OON SAR.
  3. UM will review the SAR for Medical Necessity. If the UM Care Manager recommends that the treatment is client specific and temporary and medically necessary, the UM Care Manager will submit the approved SAR to Provider Network Contracts department in order for the Client Specific Agreement to be generated.
  4. The Contract Administrator will email the Out-of-Network Single Client Application/Agreement and additional required documents to the Out-of-Network Provider for completion. This will need to be completed and returned to the Contract Administrator within 14 calendar days in order to fully execute the agreement and authorization request.

Network Contract

If there are no Network Providers who can provide the approved service within the thirty (30) mile radius and services are expected to be needed for a duration beyond ninety (90) days, enrolling the Out-of-Network Provider into the Alliance Provider Network may be determined appropriate.

  1. Provider will be notified they are approved to submit an Out of Network SAR to determine Medical Necessity.
  2. The Provider will complete and return the Out-of-Network SAR (to fax number indicated on SAR) within two weeks of receiving the OON SAR.
  3. UM will review the SAR for Medical Necessity. If the UM Care Manager recommends that the treatment is client specific and temporary and medically necessary, the UM Care Manager will submit the approved SAR to Provider Network Contracts department in order for a 90 day Client Specific Agreement to be generated. This Client Specific Agreement will cover the time period for full credentialing to occur.
  4. The Contract Administrator will email the Out-of-Network Single Client Application/Agreement and the full enrollment application to the Out-of-Network Provider for completion. This will need to be completed and returned to the Contract Administrator within 14 calendar days in order to fully execute the agreement and authorization request.
  5. The completed enrollment application will be forwarded to the Credentialing Department to initiate and complete full credentialing.
  6. Provider will need to meet Credentialing requirements in order to have a full contract with Alliance Behavioral Healthcare and to be considered to provide services past the initial 90-day Agreement.

No authorization for payment will be guaranteed.



Page last modified: April 27, 2016