If you have any questions regarding the information in CCA’s provider manual, please email Provider Relations at [email protected].
Section 6: Claims and Billing Procedures
This section is intended for Commonwealth Care Alliance providers. The information here enables providers to comply with the policies and procedures governing Commonwealth Care Alliance’s managed care plans.
Updates or changes to this section are made in the form of provider bulletins that Commonwealth Care Alliance provides to you by mail, facsimile, or Commonwealth Care Alliance’s website.
Commonwealth Care Alliance pays clean claims submitted for covered services provided to eligible Commonwealth Care Alliance members. In most cases, Commonwealth Care Alliance pays clean claims within 30 days of receipt.
The receipt date is the day that Commonwealth Care Alliance receives the claim. Claim turnaround timelines are based on the claim receipt date. Filing limits are strictly adhered to and are specified in your contract.
Please note that contracted providers must file claims no later than 90 days from date of service unless the filing limit is stipulated otherwise in contract. Non-contracted providers must file claims no later than 12 months, or 1 calendar year, after the date the services were furnished.
Commonwealth Care Alliance accepts both electronic and paper claims with industry-standard diagnosis and procedure codes that comply with the Health Information Portability and Accountability Act (HIPAA) Transaction Set Standards. Detailed instructions for completing both the CMS HCFA 1500 and UB04 claim forms are available. Download instructions.
If CCA has returned a rejected paper or electronic claim due to missing or incomplete information, please make the necessary correction as indicated in the rejection letter and resend the claim following the standard billing practice for clean claims submission within the required timely filing limit.
Providers are responsible for obtaining Prior Authorization from Commonwealth Care Alliance before providing services. Please consult your contract, the “Covered Services and Prior Authorization” section of this manual, or contact the Provider Services Department to determine if prior authorization is needed.
Claims Customer Service Department available Monday – Friday 8:30 a.m.–5:00 p.m.
EDI Support – [email protected]