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Provider Forms and Documents

Alliant Health Plans values its providers. Please find below helpful resources for all providers servicing AHP’s members.
For your convenience, we have made the forms below fillable. To enable your computer to edit the forms, follow these instructions.

General Resources

Provider Appeal Form
Member Accident Injury Form
Members/Providers: Alliant Transplant Network
Provider Update Form
Auto Pay Agreement
Alliant Network Provider Search Instructions 
Recoupment Processing Exception Request
Authorization for the Release of Protected Health Information (PHI)
Alliant Health Plans Quick Reference Guide
Out of Network Claim Payment Dispute Form
Provider Request for Out of Network MAC Payment

Medical Resources

Prior Authorization Request Form
Primary Care Physician Resource: Depression Informational Presentation and Survey
Procedures Requiring Prior Authorization 
Mohs Certifications Statement
For additional information, please contact Provider Relations at 800-664-8480 or providerrelations@alliantplans.com.
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Alliant Health Plans is committed to maintaining a broad and varied provider network to offer our members. As a part of this process, we often experience changes in the network.  As of October 1, 2021, Emory Healthcare (facilities and providers) will be out of network for Alliant. For assistance finding an in-network, please utilize the Find a Provider feature on our website or call Customer Service at (866) 403-2785.

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The DenteMax Network only applies to Alliant plans with a dental benefit. Please check the back of your Member ID Card for the DenteMax logo.

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The Provider Portal is currently undergoing maintenance and will be available in 48 hours. For assistance, please call Alliant Customer Service at (800) 811-4793.

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    Alliant Health Plans is committed to maintaining a broad and varied provider network to offer our members. As a part of this process, we often experience changes in the network.  As of October 1, 2021, Emory Healthcare (facilities and providers) will be out of network for Alliant. For assistance finding an in-network, please utilize the Find a Provider feature on our website or call Customer Service at (866) 403-2785.

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