Coverage requests and determinations

Organization Determination

An organization determination is a decision Commonwealth Care Alliance (CCA) makes about whether medical items (e.g., a wheelchair) or services are covered. Organization determinations are also called service decisions.

Prior Authorization

Prior authorization means we need to review an item or service before we agree to cover it for you. Certain items and services require review by CCA before they are covered. This ensures that our members receive the right item or service with the best value for their condition.

Request an Organization Determination

There are two ways you, your doctor, your care partner, or an appointed representative can request an organization determination, including a prior authorization:

1. Call us at: 866-610-2273 (TTY 711)
2. Mail or fax your written request to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108
Fax: 855-341-0720

For standard requests, CCA will make a decision within 14 days of receiving the organization determination request.

If your organization determination request is denied, you have the right to file an appeal.

Expedited Requests

An expedited request (also called a “fast coverage decision”) will be determined within 72 hours of receipt. Expedited requests are completed only if your care partner or care provider documents that the standard request timeframe would cause serious harm to your health or ability to function.

If it is determined by CCA that your request does not qualify as an expedited request, you will be notified and CCA will make a decision within the standard timeline of 14 days. If you disagree with the decision to move your request to the standard timeline, you have the right to file an expedited grievance (also known as a “fast grievance”).

If your organization determination request is denied by CCA, you have the right to file an appeal.

Drug Coverage Determination

A coverage determination is a decision CCA makes about whether a drug is covered. It is in your rights to request that CCA cover a drug that is not ordinarily covered.

Prior Authorization

Prior authorization means we need to review a drug before we agree to cover it for you. Certain drugs require review by CCA before they are covered. This ensures that our members receive the right drug with the best value for their condition. The list of drugs that require prior authorization is coming soon.

CCA will usually approve a request only if the preferred alternative drug or a restriction on the drug would not be as effective in treating your condition or would cause you harm.

Request a Drug Coverage Determination

You, your doctor, or an appointed representative can request a coverage determination, including a prior authorization. To request a coverage determination, please download and complete this form.

1. Mail or fax your request to:

Navitus Health Solutions
P.O. Box 1039
Appleton, WI 54912-1039
Fax: 855-668-8552

2. Call us at: 866-610-2273 (TTY 711)

Navitus Health Solutions, the pharmacy benefit manager for CCA, will review your request and make a determination. The decisions for standard requests are made no later than 72 hours from when the request was received. If waiting 72 hours could put your health at risk, you or your doctor can send a fast service request (also called an “expedited request”). A fast service request will give you the decision within 24 hours. For all fast service requests, your doctor must provide a statement that he or she confirms that this request should be expedited.

If your request is denied, you or your doctor have the right to file an appeal.

Appointing a Representative

If you need someone to file an organization or coverage determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you are making a request through an appointed representative, you should download form CMS-1696 (pdf),¹ complete it, and mail or fax it to:

Commonwealth Care Alliance
Appeals and Grievances Department
30 Winter Street
Boston, MA 02108
Fax: 857-453-4517

If you have any questions about naming your appointed representative, you can call us at 866-610-2273 (TTY 711).