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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

Appointment of Representative (Form CMS-1696)*

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

The Patient Health Questionnaire 2 Overview (PHQ 2)

The Patient Health Questionnaire (PHQ 9)

Mental Status Exam

CAGE Questionnaire

Prior Authorization Forms

FAQs: Prior Authorization Requests – Massachusetts

Esketamine Prior Authorization Request

PA Form – Repetitive Transcranial Magnetic Stimulation Request

PA Form – Out of Network Psychological and Neuropsychological Assessment

PA Form – Cardiac Imaging


PA Form – PET – PET CT

Standard Prior Authorization Request Form

CCA ECT Authorization Request

Claims Requirements

2023 Claims Requirements 1500 Professional Form – Massachusetts

2023 Claims Requirements UB Institutional Form – Massachusetts

CMS Provider Directory Requirements

Guidance to Verify Adequate Networks & Current Provider Directories

Provider Directory Requirements

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