Commonwealth Care Alliance

Commonwealth Care Alliance

Providers > Provider Resources > Health Plan Operations Improvements are Underway

Health Plan Operations Improvements are Underway

Good business practice is central to the success of our provider delivery system and in supporting excellent clinical care. As part of our efforts to better serve both our members and provider partners, Commonwealth Care Alliance is focused on improving our health plan operations and streamlining business processes. Several initiatives are underway to improve our services, including:

InterQual Application
Commonwealth Care Alliance is instituting the InterQual application, with the goal of consistently and accurately identifying the appropriate level of care for hospital-based services. This will help us work with our hospital partners in determining observation vs. inpatient status in a manner that aligns us with other payers in Massachusetts.

Hospital Admissions Process
We are currently working with our hospital partners to ensure efficient clinical operations related to hospital admissions for Commonwealth Care Alliance members. Please note our policies:

  • Notification, prior authorization, and clinical information are required in order to receive payments for admissions.
  • Authorization does not guarantee payment. Authorization is based on medical necessity and member eligibility at the time of admission. Claims for inpatient admissions submitted without authorization will be denied.

Upon notification, an inpatient RN clinical coordinator will conduct an admission review to determine the medical necessity and level of care. For questions, contact Barbara Mitzan (857-246-8828) or DeAnna Jaggi (413-314-3828) in our Clinical Operations Department.

Last Updated 12/21/2016