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CCA Referral Services

Together we can create a better experience and better outcomes for your patients with complex needs.

Administrative Forms and Notices

CCA SCO and One Care Prior Authorization List

BH Inpatient Notification of Admission Form

Appointment of Representative (Form CMS-1696)*

2024-2025 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)

The Patient Health Questionnaire (PHQ 9)

Mental Status Exam

CAGE Questionnaire

Provider Roster

Prior Authorization Forms

Esketamine Prior Authorization Request

FAQs: Prior Authorization Requests – Massachusetts

Out of Network ECT Authorization Request

PA Form – Repetitive Transcranial Magnetic Stimulation Request

PA Form – Out of Network Psychological and Neuropsychological Assessment

PA Form – Cardiac Imaging

PA Form – CT/CTA/MRI

PA Form – PET – PET CT

Standard Prior Authorization Request Form

CMS Provider Directory Requirements

Guidance to Verify Adequate Networks & Current Provider Directories

Provider Directory Requirements

Other Important Forms

Chronic Condition Provider Attestation Form


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