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Forms, Lists and Notices

Here you will find a wide variety of provider materials and information. If you cannot find what you need, please call Provider Relations at 617-600-3195 or email us at providerrelations@commonwealthcare.org.

 

Covered Services & Prior Authorization Requirements (pdf)Appointment of Representative (pdf)Durable Medical Equipment (DME) (pdf)EDI Transactions Questionnaire Form (pdf)Elec. Funds Transfer (EFT) & Remittance Advice (ERA) (pdf)Notice of Privacy Practices (pdf)Program Referral Form – Senior Care Options (pdf)Program Referral form – One Care (pdf)Request for Claim Review Form (pdf)2017 CMS Quality Star Rating (pdf)2017 CMS Quality Star Rating in Spanish (pdf)

Prior Authorization Forms

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

Form Instructions

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


CMS Provider Directory Requirements

The Centers for Medicare & Medicaid Services (CMS) issued refined regulations in 2016 requiring Medicare Advantage health plans to have more comprehensive and up-to-date provider directories. Inaccurate provider directories have a severe impact on members’ ability to access in-network providers, correct service locations, and important facts about providers’ practices.

We are committed to adhering to the current CMS requirements. To ensure success, we have partnered with LexisNexis to perform the provider outreach on our behalf. Providers will be contacted by LexisNexis to provide updated demographics.

You can learn more about the CMS Provider Directory regulations by reviewing the following documents:  


Guidance to Verify that Networks are Adequate and Provider Directories are Current (pdf)   
Provider Directory Requirements – Update (pdf)

If you have any questions, please contact Provider Relations at: ProviderRelations@commonwealthcare.org.

 

Health plan operations improvements are under way

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, we are focused on improving our health plan operations and streamlining business processes. Several initiatives are underway to improve our services, including

  • InterQual Application

    We are 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.

ICD-10 Resources

What You Need to Know about ICD-10

The International Classification of Disease tenth revision (ICD-10) is a system of coding created by the World Health Organization that notes various medical records including diseases, symptoms, abnormal findings and external causes of injury. ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The links listed below will introduce you to ICD-10, explain why it is necessary and provide you the information you will need to understand it.


ICD-10 Testing
Testing is a critical component of ICD-10 transition. If Emdeon is your claims clearinghouse, please contact them directly to begin testing. Visit Emdeon ICD-10* FAQ’s, handbooks on testing, and other online resources.

If Emdeon is not your claims clearinghouse, the Commonwealth Care Alliance, Claims Department will begin testing with providers in June. We will test claims and processes using ICD-10 to make sure the new code set will be processed correctly in the live claims’ environment as of October 1, 2015. If you are ready to begin testing, please email providerrelations@commonwealthcare.org and we will schedule your testing date.

Stay up to date on ICD-10!

To stay current with the latest ICD-10 updates, including Quick Tips for Submitting ICD-10 Test Files to MassHealth, ICD-10 Provider FAQs, Provider Bulletins and Job Aids, please visit the Mass.gov ICD-10* Web Page and click on ICD Implementation.


For general questions on ICD-10, please email ProviderRelations@commonwealthcare.org.

Here is a list of resources about ICD-10 for your use:
ICD-10 Training Resources

Resources

Free/Charge

Medicare Learning Network’s ICD-10 Coding Basics (video)*

Free

Practice Managers Guide ICD-10 (video)*

Free

CMS Introduction to ICD-10 Coding (video)*

Free

CMS – IC-10 (further resources and Updates)*

Free

Codebusters – ICD-10 Training*

Free

Alison – Free learning network*

Free

World Health Organization – ICD-10 Interactive Self learning Tool*

Free

MAXIM – ICD-10 Training*

Charge

AAPC – ICD-10 Training for Coders*

Charge

Evolve – ICD-10 Online Training Modules*

Charge

Optum Coding – ICD-10 Impact to Nursing Documentation*

Charge

Bridge Front – Your Single Source for ICD-10 Education

Charge

Solutions*

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