Skip to main content

If you have any questions regarding the information in CCA’s provider manual, please email Provider Relations at [email protected].

Section 4: Covered Services & Prior Authorization Requirements

Table of Coverage

In accordance with the member’s evidence of coverage, certain services performed by contracted providers require a prior authorization before being rendered. Commonwealth Care Alliance’s Authorization and Utilization Management Department is responsible for reviewing prior authorization service requests from providers. All requests (except Behavioral Health,  Specialized Radiology Services & Inpatient/Observation Admissions – please see below for details) must be faxed to 855-341-0720 using the Standardized Prior Authorization Request Form along with the necessary clinical documentation to support the request. Download the form.

  • Behavioral Health prior authorization service requests must be faxed to 855-341-0720 using the appropriate form for the service requested along with the necessary clinical documentation to support the request. Download the forms.
  • Specialized Radiology prior authorization service requests must be faxed to 855-341-0720 using the appropriate form for the service requested along with the necessary clinical documentation to support the request. Download the forms.
  • Inpatient/Observation Admissions prior authorization service requests must be faxed to 855-811-3467 using the appropriate form for the service requested along with the necessary clinical documentation to support the request. Download the forms.

Prior authorization decisions will be made no later than fourteen (14) calendar days after CCA receives the request (or within seventy-two [72] hours for expedited requests). Medicare Part B medication requests are made no later than seventy-two (72) hours for standard request and twenty-four (24) hours for expedited requests.  Services requiring prior authorization by CCA are listed below. If a requested service or item is not listed below, please call Provider Services at 866-420-9332 for clarification.

Covered Services & Prior Authorization Requirements

Download:

When to request an authorization to be expedited:

A member, or any physician may request that CCA expedite an organization determination (prior authorization request) when the member or his/her physician believes that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.

Durable Medical Equipment (DME)

For a code specific list of Durable Medical Equipment (DME) and other services requiring Prior Authorization (PA) for Commonwealth Care Alliance’s One Care and SCO programs.

Durable Medical Equipment (DME)

Download:

Medical Necessity Guidelines

All Medical Necessity Guidelines can be located on the Commonwealth Care Alliance website, under the Medical Guidelines section of the Provider Page. Please click here for more information.