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 | CMS Provider Directory Requirements
CCA Referral Services
Together we can create a better experience and better outcomes for your patients with complex needs.
Administrative Forms and Notices
BH Inpatient Notification of Admission Form
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Appointment of Representative (Form CMS-1696)*
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2024 PA Select Drug Exception List – Massachusetts
2024 Prior Authorization Requirements – Massachusetts
Coverage Requests and Determinations – Massachusetts
Learn how we make coverage decisions and how to make requests for coverage.
2024 Durable Medical Equipment – Massachusetts
2024 Ambulatory – Outpatient Surgery Exception List – Massachusetts
EDI Transactions Questionnaire Form – Massachusetts
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
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FAQs: Prior Authorization Requests – Massachusetts
Out of Network ECT Authorization Request
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PA Form – Repetitive Transcranial Magnetic Stimulation Request
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PA Form – Out of Network Psychological and Neuropsychological Assessment
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PA Form – Cardiac Imaging
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PA Form – CT/CTA/MRI
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PA Form – PET – PET CT
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Standard Prior Authorization Request Form
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CMS Provider Directory Requirements
Guidance to Verify Adequate Networks & Current Provider Directories
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Provider Directory Requirements
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Other Important Forms
Chronic Condition Provider Attestation Form
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