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Spring Into CCA’s Provider e-Newsletter

Our Spring Provider e-Newsletter has all the latest information to keep you up to date on any changes to CCA’s policies, practices, or procedures, including updated billing and reimbursement information.

During the rapidly evolving situation around COVID-19, Commonwealth Care Alliance (CCA) continues to follow the recommendations from the Centers for Disease Control and Prevention (CDC) and the Massachusetts Department of Public Health (DPH) to keep our members and employees safe. We encourage providers to consult the CDC, the DPH, and Mass.Gov Coronavirus websites for the most up to date information. Please check the CCA Provider page daily; we will continue to provide updates as they become available.

As of March 2, 2020, CCA’s new DME & Supply Procurement Unit (DSPU) centralizes fulfillment operations and processes. The DSPU replaces independent fulfillment teams formerly in place at Clinical Groups West, Central, and East.

The DSPU first phase of operations will serve members under the care of the Clinical Groups only. The DSPU looks forward to streamlining the fulfillment process for members and relieving the administrative burden on care partners.

In support of CMS requirements, please note that CCA requires a prescription for all DME and medical supply orders. The prescription also becomes important supporting documentation if a vendor is asked to submit records for a claims audit.

Commonwealth Care Alliance has partnered with NEHEN to provide real-time member eligibility verification beginning March 30, 2020. Providers who are currently enrolled with NEHEN can use this value added service to obtain eligibility confirmation faster.

Providers can verify eligibility using any of the following options:

New England Healthcare Exchange Network (NEHEN)
NEHEN is a consortium of regional payers and providers who have designed and implemented a secure and innovative health information exchange for reducing administrative costs and improving the quality, safety, and efficiency of patient care. NEHEN technology has changed the way administrative, clinical, exchange, and ePrescribing processes are performed in member organizations. NEHEN offers its members tools to address the challenges faced by the healthcare industry.

Eligibility verification services
The following real-time eligibility verification services are now available:

  • Web portal, batch or integrated real-time transactions to validate all members within a batch at one time
  • Single individual searches to validate eligibility for a single member
  • Discovery feature searches to locate the proper payer information for a member; NEHEN can check eligibility against 13 participating health plans simultaneously!
  • 24/7 system availability
  • Advanced activities reporting and analytics related to transactions conducted

How to become a NEHEN member

Thank you for your continued support and the quality care you provide to CCA members. If you have any questions, please contact CCA Provider Services at 866-610-2273.

Commonwealth Care Alliance has partnered with Performant Recovery, Inc. to review provider claims. Performant identifies and resolves underpayments and overpayments due to erroneous claims coding and/or incorrect claim adjudication.

If Performant identifies a need to review claims, CCA providers must follow instructions in Performant’s letters requesting medical records. Performant will follow these timelines in the letter based on CCA’s guidance. Providers who do not follow the instructions risk the possibility of claims being retracted for “non-response,” as this is considered an agreement with the review findings.

Performant will provide specialized CCA provider support 9 a.m. to 5 p.m. EST, Monday–Friday during a review process. Performant will provide a contact number in their letters. If you have questions in the meantime, please contact CCA Provider Services at 866-610-2273.

Ever wonder what CCA uses to make decisions on care, treatment, and authorization of services for your patients?

CCA annually develops or selects and approves clinical criteria to ensure medical necessity. CCA utilizes the following criteria in the prescribed order:

  • National coverage determinations (NCD)
  • Local coverage determinations (LCD)
  • InterQual
  • CCA medical necessity guidelines (MNG)
  • CCA decision support tools

When Medicare NCD or LCD guidelines are not available, CCA uses InterQual modules for the following services:

  • Home health
  • DME
  • Inpatient level of care
  • Procedures
  • Advanced imaging

CCA also uses internally developed Medical Necessity Guidelines (MNG) to review the appropriateness of targeted services. CCA reviews and updates these documents at least annually, or as new treatments, applications and technologies are adopted as generally accepted professional medical practice.

For specific information please visit our Medical Policies page.

In the coming months, CCA will be establishing a dedicated provider services line to give providers access to more enhanced services. Keep an eye out for a more formal announcement in the near future.

Are you a group practice with more than 10 providers and need to add a new provider?

CCA has made this process much easier. Please send an email to [email protected] and we will send you the updated provider roster form. Providers with fewer than 10 clinicians may continue to utilize the HCAS form found at https://www.hcasma.org/Resources.htm. Please email any updates to [email protected].

Check your listing in the CCA Provider Directory to ensure that your name, address, and phone number are correct. CCA wants to be sure that patients can find you when seeking medical care. If you are a primary care provider, ensure that we accurately have you listed as accepting new patients. If you need to make any updates, please send an email to [email protected]

You can find key resources to support CCA members in our updated Provider Manual. This includes an up-to-date contact list available online. View the Provider Manual Contact List.

Keeping your information up-to-date in our Provider Directory helps your practice by making it easier for our members to find your practice locations. Updating your information in our health plan provider directories also helps our members:

  • Get easy access to your services.
  • Receive important information about your practice
  • Find accurate information about where to find your practice.

Quarterly Updates Now Easier with LexisNexis
CMS requires us to list accurate provider information in our health plan provider directories. To simplify the process for you, we’ve partnered with LexisNexis. Each quarter, you will be contacted by LexisNexis and asked to provide updated information about your locations and services.

Your Assistance is Greatly Appreciated!
We ask that you provide a complete and prompt response to LexisNexis every quarter. If you wish to provide your updated information to CCA directly, please email us at [email protected] and a CCA representative will contact you.

Learn more about the CMS Provider Directory regulations on our website here.

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