Summer 2021: Volume 4, Issue 3

At Commonwealth Care Alliance (CCA), we are dedicated to continuing to support our provider community, who are instrumental in providing the best possible care to the members we serve.

In recent months, CCA has heard significant concerns from our provider community in regard to the administrative burden providers are experiencing when submitting corrected claims to CCA. Effective June 1, 2021, we are pleased to announce that CCA has implemented an industry-standard process where providers can now submit their corrected claims electronically. We are in the process of updating our Provider Manual and EDI companion guides, and appropriate communication will be shared once these documents are updated. Until we update the Provider Manual and EDI companion guides, we are providing a quick reference guide on how corrected claims can be submitted electronically.

How to Submit Corrected Claims Electronically:

Resubmission (Frequency Code 7):
Only submit resubmissions for claims that have been finalized.
Submit one corrected claim for each one finalized claim.

• In Loop 2300:
  • In the claim segment, field CLM05-3 needs to have a value of 7.
  • In the REF segment, use qualifier F8 and put in the CCA claim number of the original submission.

Full Void (Frequency Code 8):
Only submit voids for claims that have been finalized.
Submit one void for each one finalized claim.
Only submit voids when the entire claim is to be voided.

• In Loop 2300:
  • In the claim segment, field CLM05-3 needs to have a value of 8.
  • In the REF segment, use qualifier F8 and put in the CCA claim number of the original submission.

If you have any questions, please contact CCA Customer Service at 800-306-0732. For EDI support, please email [email protected].

At Commonwealth Care Alliance (CCA), we are dedicated to improving care for individuals dually eligible for MassHealth and Medicare with complex medical, behavioral health, and social needs. Our mission is to provide the best possible care to the members we serve.

Following the precedent established by the Centers for Medicare and Medicaid Services, CCA recognizes that the frequency of readmissions to an acute care hospital shortly after discharge is an index for quality of care. Thus, CCA has implemented a process for reviewing such readmissions.

Effective July 1, 2021, CCA will be instituting a revised payment policy for readmissions to the same hospital or hospital system within 30 days. CCA and its affiliates will conduct post-pay readmission reviews to determine if the readmission could have been prevented due to one or more of the following conditions:

• If the readmission was medically unnecessary,
• If the readmission resulted from a premature discharge from the same hospital, or
• If the readmission was the result of circumvention of the Prospective Payment System by the same hospital.

Note: The above guidelines are only applicable for review if the member entered the same acute facility within 30 days.

For more details, please visit our website at commonwealthcarealliance.org. The Readmissions Within 30 Days policy can be found on the “For Providers” section under Policies and Guidelines: Payment Policies.

If you have any questions regarding this letter, please contact the CCA Provider Services team at 866-420-9332.

At Commonwealth Care Alliance (CCA), we’re committed to supporting our provider partners, so that together we can deliver the highest-quality, individualized care to our members. For this reason, we’ve updated our website (www.commonwealthcarealliance.org) to feature an enhanced navigation system and richer content—to help you quickly and easily find the information you need from CCA. Below we’ve outlined some of the key updates and features of our new site.

Enhanced navigation: The new site features three easy ways to find what you need:

• Four main navigation buttons located at the top of the Provider page, for easy access to our Provider Manual and other important forms and documents
• “Quick Links” that help you drill down by topic and access other key information, such as our trainings and programs
• A hamburger menu (drop-down) that helps you navigate to other sections of the site when needed

New content and improved page organization, including:

• A Provider News page that combines the latest newsletter and COVID-19 alerts from CCA
• An integrated Policies and Guidelines section that combines clinical, quality, and payment information
• Easier access to our Provider Directory and a detailed service map

For questions or support, you can contact us at 866-420-9332. As always, thank you for your continued partnership in serving CCA members.

As a Commonwealth Care Alliance (CCA) contracted provider, you have an obligation to coordinate members’ care with contracted, in-network providers. This includes all services, such as laboratory, durable medical equipment, radiology, behavioral health providers, skilled nursing facilities, long-term support services, and many other specialties.

Before you establish a referral relationship with a provider, please take a moment to confirm that the provider in question currently participates in the CCA network. Please also confirm that the provider currently participates with your patient’s plan, such as Senior Care Options or One Care.

There are two ways to confirm in-network status:

1. Check providers’ participation status on the Advanced Search of the CCA Provider Directory, found here: https://provider-directory.commonwealthcarealliance.org/Form/Index
2. Contact the CCA Provider Services Team at 1-866-420-9332

Your cooperation in referring to in-network providers is greatly appreciated. This practice will promote excellent care coordination with high-quality, CCA providers who care and provide services for CCA members.

The Standard Prior Authorization form is required for all prior authorization submissions. It should be submitted prior to delivering services to the member. You can find the form here: https://www.commonwealthcarealliance.org/ma/providers/forms-and-referrals/

Required Information for Processing Authorizations

• All required fields on the PA form (marked with an asterisk *) are necessary for processing requests in a timely manner. Not including required information can cause delays in processing or denials.
• The specific information below is frequently missed on requests, which causes delays and incorrect denials. Please make sure to include this information as well as all other required information.
  1. Servicing facility represents the location where the requested services will take place. It is not sufficient to only list the Servicing Provider’s information—we also need the location where they will perform the services.
  2. Diagnosis & CPT/HCPCS codes
     • – CPT/HCPCS codes and description of services
     • – The frequency and number of units for each code
     • – The dates of service
     • – ICD-10 diagnostic codes
  3. Clinical documentation to justify the requested services must be attached when submitting a PA form. This includes office notes and any written/MD orders. Lack of supporting clinical information delays the decision and your ability to provide the requested service.

Submission of Duplicate PA Requests

PA requests should be submitted only once, unless there is an update. Please do not submit a duplicate request if you are waiting on a decision. Authorizations are processed within regulatory timeframes (please see the FAQ on Authorization Requests located at the link provided at the top of this page). If you are looking for the status of a PA request that you have submitted, please contact CCA Provider Services at 866-420-9332.

Expedited PA Requests

Expedited requests should only be made when waiting for the decision under the standard time frame could place the member’s life, health, or ability to regain maximum function in serious jeopardy.

It is estimated that as much as 67% of all emergency department visits are avoidable.* CCA’s instED^® program helps ease this burdensome statistic, allowing our members to receive the urgent medical care they need in the comfort of their own home.

instED is a reliable resource that fills the gap between primary care and emergency care—even for those with significant health needs. With instED, you’ll have peace of mind knowing your patients are cared for by highly trained paramedics, and that you’ll be kept informed of the care they receive.

How to Request an instED Visit

It’s quick and easy for providers and patients to request an instED visit.
Go to www.instED.us¹ or call 1-833-9-INSTED (1-833-946-7833).

instED visits are free of charge for CCA plan members.
For more information, please contact [email protected].

* Stanton, M. W., & Rutherford, M. K. (2005). The high concentration of U.S. health care expenditures. Agency for Healthcare Research and Quality, 19, 06-0060. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/ costs/expriach/

The instED program is not available in all areas. Other in-home urgent care providers are available in the CCA network. For any life-threatening conditions or medical issues that need immediate attention, call 911.

You can find key resources to support CCA members in our updated Provider Manual. This includes an up-to-date contact list available online. View the Provider Manual Contact List.