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
Appointment of Representative (Form CMS-1696)*
view:
2023 PA Select Drug Exception List – Massachusetts
2023 Prior Authorization Requirements – Massachusetts
Coverage Requests and Determinations – Massachusetts
Learn how we make coverage decisions and how to make requests for coverage.
2023 Durable Medical Equipment – Massachusetts
2023 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
Physician Peer-to-Peer Request Form
view:
The Patient Health Questionnaire 2 Overview (PHQ 2)
view:
The Patient Health Questionnaire (PHQ 9)
view:
Mental Status Exam
view:
CAGE Questionnaire
view:
Esketamine Prior Authorization Request
view:
FAQs: Prior Authorization Requests – Massachusetts
Out of Network ECT Authorization Request
view:
PA Form – Repetitive Transcranial Magnetic Stimulation Request
view:
PA Form – Out of Network Psychological and Neuropsychological Assessment
view:
PA Form – Cardiac Imaging
view:
PA Form – CT/CTA/MRI
view:
PA Form – PET – PET CT
view:
Standard Prior Authorization Request Form
view:
CMS Provider Directory Requirements
Guidance to Verify Adequate Networks & Current Provider Directories
view:
Provider Directory Requirements
view:
Need more information?
We’re here to help.
We’re here to help.