Forms and Referrals
We want to make it easy to work together so our members, and your patients, have the best experience possible. Here you can access important provider forms and learn how to refer a patient to CCA.
Jump to: Administrative Forms & Notices | Prior Authorization Forms
CCA Referral Services
Together we can create a better experience and better outcomes for your patients with complex needs.
Administrative Forms and Notices
Provider Contracting Application
CCA SCO and One Care Prior Authorization List
BH Inpatient Notification of Admission Form
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Coverage Requests and Determinations – Massachusetts
Learn how we make coverage decisions and how to make requests for coverage.
Notice of Privacy Practices – Massachusetts
Commonwealth Care Alliance, Inc., is required by law (i) to protect the privacy of your Medical Information
The Patient Health Questionnaire 2 Overview (PHQ 2)
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The Patient Health Questionnaire (PHQ 9)
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Mental Status Exam
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CAGE Questionnaire
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Provider Roster
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Esketamine Prior Authorization Request
Out of Network ECT Authorization Request
PA Form – Repetitive Transcranial Magnetic Stimulation Request
PA Form – Out of Network Psychological and Neuropsychological Assessment
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PA Form – Cardiac Imaging
PA Form – CT/CTA/MRI
PA Form – PET – PET CT
Standard Prior Authorization Request Form
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Other Important Forms
Address for Refund Checks
Chronic Condition Provider Attestation Form
Claim Recovery Refund Check Form
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Frail Elder Waiver Provider Form
High Dollar Claims
Itemized Bill Cover Sheet
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Overpayment Recovery Form
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Need more information?
We’re here to help.
We’re here to help.
