Commonwealth Care Alliance

Commonwealth Care Alliance

Providers > Provider Resources > Administrative Forms, Lists and Notices

Administrative Forms, Lists and Notices

Download Appointment of Representative (Form CMS-1696)* (pdf)
Download Covered Services and Prior Authorization Requirements
Download Durable Medical Equipment (DME) and other services requiring Prior Authorization from Provider Manual
Download EDI Transactions  Questionnaire From (pdf)
Download Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Form (pdf)
Click here for the Notice of Privacy Practices (pdf)
Download Program Referral Form – Senior Care Options (pdf)
Download Program Referral form – One Care (pdf)
Download Request for Claim Review Form (pdf)
Download the 2016 CMS Quality Star Rating for Senior Care Options (pdf)

Prior Authorization Forms

Download New Prior Authorization Standardized Request Form – Mass Collaborative / FAQs (pdf)
Download Prior Authorization Standardized Request Form – Behavioral Health (pdf)
Download Prior Authorization Form – Massachusetts Medication Requests (pdf)
Download Prior Authorization Form – Repetitive Transcranial Magnetic Stimulation Request (pdf)
Download Prior Authorization Form – Psychological and Neuropsychological Assessment (pdf)
Download Prior Authorization Form – Cardiac Imagining (pdf)
Download Prior Authorization Form – CT/CTA/MRI (pdf)
Download Prior Authorization Form – PET – PET CT (pdf)

Form Instructions

Download Claims Requirements 1500 Professional Form (pdf)
Download Claims Requirements UB Institutional Form (pdf)


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Last Updated 02/02/2017