Forms

IMPORTANT INFORMATION - QUEST Integration Registration - Effective July 1, 2021, Provider enrollment and registration is required with the Department of Human Services (DHS), Med-QUEST Division to acquire a State of Hawai`i Medicaid ID prior to submitting an application to QUEST Integration Health Plans to proceed with credentialing.

AlohaCare will inactivate our credentialing process upon confirmation as to whether the applicant has not completed DHS Med-QUEST's enrollment and registration process. We will issue a notification to the applicant with regard to our determination if it results in our inability to proceed with credentialing.

• AlohaCare Provider Credentialing Application & Enrollment Form:
  • 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.
• Address/Contact Update/Change Form
  • Update contact or payment information.
  • Change the address of an existing practice location.
  • Add another practice location to the same group/practice. Please complete the AlohaCare Provider Credentialing Application & Enrollment form if you are Credentialed/Participating with AlohaCare and you are joining a new group/practice.
• Adult Health Risk Assessment
• Child Health Risk Assessment
• Provider Panel Status Update Form: Complete this form to inform AlohaCare about your panel status and let us know whether you have the ability to accept new members.
• Request for Taxpayer Identification Number and Certification (W-9 Form): Fill out the W-9 Form for our files. We’re required to have your taxpayer identification number and certification on record. 
• QI Service Coordination Referral Form: Refer a member to Service Coordination.
• Hospice Information for Medicare Part D Plans: Complete this form to update hospice status or to override an "Hospice A3 Reject."
• PCP Change Form: This form lets members change their Primary Care Provider (PCP).
• Waiver of Liability Form: For Medicare Non-Par Providers Only
  • Typically appeals are written requests made by providers disagreeing with the resolution of a grievance. Medicare non-par providers may file an appeal for a denial of payment without submitting a grievance first.
  • Medicare non-par providers must complete the Waiver of Liability Form agreeing not to bill an enrollee regardless of the outcome of the appeal.
• Adverse Event: Report all incidents and events that harm our members who receive long-term services and supports (LTSS).
  • Harm can include lack of prescribed services (i.e. caregiver doesn't show up).
  • An Adverse Event is an occurrence that may cause harm to a member or LTSS provider. The Adverse Event indicates risk (i.e. abuse, neglect, exploitation) to a member to LTSS provider's health or welfare.
• Injury and Illness Form: Please assist member with completing this form if their injury or illness is related to a work or automotive incident or accident.
• Older Adult Provider Assessment Form: Provider fills out a form about the patient's Advance Care Planning, Functional Status, Assessment, Pain Assessment, and Medication Review for older adults.
• Community Integration Services (CIS) - Supportive Housing Services - These services, when paired with affordable housing, are a way to help individuals experiencing homelessness to locate and stay in housing.
  • CIS Referral Form
  • CIS Member Consent Form
  • CIS Health Action Plan Addendum
  • CIS Member Assessment and Reassessment Tool
  • CIS Billing Guidelines