Add a New Practitioner Form
Use this form to request a new practitioner.
We bridge the gap between providers and employers. We partner with you to bring high-quality, fairly priced services to employers, employees, and their families. Our strong employer connections and employee guidance initiatives can benefit your practice, hospital, or health system while helping you care for your local community.
To date, we’ve partnered with 38,000+ doctors and healthcare providers across the Midwest, offering coverage to more than 115,000 people.
All the forms you need in one place
Use this form to request a new practitioner.
Use this form to change/term a practitioner, change/term a location, add a location, update a billing address, or update your contact information.
For participating providers only.
Thank you for partnering with The Alliance! As a participating provider, you can find all relevant policies and procedures below.
For accurate claim(s) filing, follow the submission instructions on the patient’s ID card. Most of our enrollees’ claims are submitted directly to The Alliance®, unless otherwise indicated on the ID card.
Sending and receiving claims via Electronic Data Interchange (EDI) is a great way to ensure more timely payments. With EDI claims, we’re able to reprice and send the claim to the Third-Party Administrator (TPA) in just a few hours. We work with several clearinghouses for electronic claims submissions.
The Alliance payer identification numbers are as follows:
RelayHealth (McKesson): Payer ID # 2712 (CMS-1500) and # 1935 (UB)
Emdeon/Optum EDI/most others: Payer ID # 88461
Contact us if you’d like EDI connectivity or to use an electronic submitter that is not listed.
Filing paper claims? Please send these to:
P.O. Box 44365
Madison, WI 53744-4365
Send corrected claims to The Alliance to report modifications to a previously submitted claim. The preferred method for submitting corrected claims is via EDI. To ensure that corrected claims are processed by The Alliance appropriately, please report claims as follows:
Additionally, please report the data fields as follows:
Failure to follow these guidelines may cause the claim to process and deny as a duplicate claim submission. Make sure to submit the entire original claim with all line items, not just the line being corrected. The Alliance will apply the contract provisions to the reported corrected claim and forward it to the relevant TPA for processing.
Need to determine the status of a previously submitted claim? Please do not submit a duplicate claim – it won’t result in returning the status of the claim and adds more costs and resources to the claims process. Please proceed with one of the following options instead (in order of effectiveness):
Find reimbursement information on bundled services, category II codes, coding edits, a modifier reference guide, and more.
Head to our Provider Networks page to view our Comprehensive Network service area, which extends from Wisconsin into Michigan, Minnesota, Illinois, and Iowa.
Healthcare practitioners participating in The Alliance® network must successfully complete the credentialing process to ensure they are qualified to meet prevailing standards for quality of care and professional conduct.
We credential licensed healthcare practitioners who provide services on behalf of a contracted provider organization and are marketed to members through our provider directories. These include the following practitioner types:
The Alliance has partnered with CAQH to streamline the application and credentials verification process. We encourage contracted practitioners to maintain current and complete profiles within the CAQH Provider Data Portal. For assistance with your CAQH profile, please review the Practitioner Quick Reference Guide or call the CAQH Solutions Center at 1-888-599-1771.
If your CAQH profile is current and complete, no additional effort on your part may be required to complete the credentialing process. If any required information or documents are expired or missing from your profile, CAQH and/or The Alliance Provider Operations team will contact you to request updates.
The Alliance has a few different logos that may appear on member ID Cards (represented below). These are the most current logos that could appear on the front or back of the ID Card.
These logos may also appear on member ID cards. Any of these logos are acceptable and mean your organization is in-network for members and their dependents.
Review important contract reminders for participating providers. Please note that this overview is not intended to include all contractual provider obligations.
Provider will offer 24/7 telephone access to patients for their safety and protection, and will have procedures in place to respond to patients’ calls and requests after normal business hours.
Provider will not balance bill the member beyond patient responsibility, such as co-payments, coinsurance, and deductibles.
Facilities (and other designated providers) will send The Alliance information regarding any modifications related to their chargemaster.
Provider will notify The Alliance in a timely manner of claim(s) processed or submitted incorrectly.
Provider will submit claims according to regulations and in a timely manner to The Alliance.
Provider will comply with the requirements of The Alliance’s Provider Credentialing Program, including the timely completion of a credentialing application if requested.
Provider will provide services to all individuals in a prompt manner, consistent with professional, clinical, and ethical standards and without bias.
Using the Provider Update Form, provider will notify The Alliance 30 business days prior to a change
Participating Providers acknowledge that The Alliance enrollees have the right to freedom of choice of providers, including, without limitation, primary care and specialty providers. Participating providers acknowledge and agree that the provision of care for an enrollee will not be conditioned on the enrollee first receiving primary care or other healthcare services from the participating provider’s choice of providers.
When you have questions, either The Alliance or the third-party administrator (TPA) may be best able to provide an answer.
Use this guide to determine who to contact:
Call The Alliance at 800.223.4139
Call the Third-Party Administrator (TPA) found on the enrollee’s ID Card