Provider Important Documents
Effective January 1, 2025, Commonwealth Care Alliance Rhode Island, LLC is no longer offering the CCA Medicare Preferred (PPO), CCA Medicare Value (PPO), and CCA Medicare Maximum (HMO D-SNP) plans.
Below please find resources you may need for any outstanding claims, contact information, provider manuals and more. For any additional questions not addressed with the resources below, please contact our Provider Services team for assistance at 866-420-9332, 8 am to 5 pm, Monday through Friday.
Provider Manual | Clinical Guidelines | Medical Necessity Guidelines | Payment Policies
Provider Documents
2024 CCA Medicare Advantage Provider Manual – Rhode Island
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Appointment of Representative (Form CMS-1696)*
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Notice of Privacy Practices – Rhode Island
Commonwealth Care Alliance, Inc., is required by law (i) to protect the privacy of your Medical Information
Clinical Guidelines
Guidelines and Assessment Tools
| GUIDELINES | SOURCE | APPROVED BY CCA HEALTH |
| Cervical Cancer Screening Guidelines | 2019 USPSTF | September 2022 |
| Disability Competent Care (Webinar) | Resources for Integrated Care 2017 | September 2022 |
| Depression Screening for At Risk Individuals | 2016 USPSTF | September 2022 |
| Guideline for Prescribing Opioids for Chronic Pain | CDC 2019 | September 2022 |
Assessment Tools
| TOPIC | SOURCE | CCA HEALTH APPROVED DATE |
| PROMIS-29 | PROMIS® | September 2022 |
| PHQ-9 | SAMHSA | September 2022 |
| PHQ-9 Spanish | SAMHSA | September 2022 |
| AUDIT | WHO | September 2022 |
| AUDIT Spanish | WHO | September 2022 |
| DAST | CDC | September 2022 |
| DAST Spanish | CDC | September 2022 |
CCA Medical Necessity Guidelines
Acupuncture
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Balloon Dilation of the Eustachian Tube
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Chimeric Antigen Receptor (CAR) T-Cell Therapy
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Chiropractic Services
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Clinical Trials, Routine Patient Care Costs
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Continuous Glucose Monitors (CGM)
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Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility
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Excision of Excessive Skin & Subcutaneous Tissue
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Experimental and Investigational Services
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Gender Affirming Surgery and Related Procedures
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Genetic Testing BRCA-Related Breast and/or Ovarian Cancer Syndrome
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Genetic and Molecular Testing
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Home Health Services – Medicare Advantage
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Hospital Beds
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Hyaluronic Acid Injection for Knee Osteoarthritis
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Intravenous Iron Infusion
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Leqembi (lecanemab-irmb)
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Manual Wheelchair Power Accessories
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Medical Necessity
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Medicare Part B Step Therapy
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MyoPro Upper Limb Compensatory Device
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New-to-Market Part B Medications
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Non-Covered Benefit
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Non-Preferred DME
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Out of Network Coverage
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Part B Drugs Requiring Prior Authorization
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Peroral Endoscopic Myotomy (POEM)
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Power Operated Vehicle
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Power Seat Lift Chairs
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Pressure Reducing Support Surfaces – Group 2 and Group 3
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Pulmonary Artery Pressure Monitoring (CardioMEMS)
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Recommendations for Intermittent Skilled Therapy in a Nursing Facility (NF)
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Repairs and Modifications of Durable Medical Equipment (DME)
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Rhinoplasty and Septoplasty
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Skilled Nursing Facility (SNF) Services Under Medicare Part A
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Skin and Soft Tissue Substitutes
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Subacute Level of Care in a Skilled Nursing Facility (SNF) Under Medicare Part A
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Behavioral Health Documentation Guidelines
Behavioral Health Outpatient Documentation Guidelines
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CCA Health Behavioral Health Performance Specifications
Acute Treatment Services (ATS) ASAM Level 3.7
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Clinical Stabilization Services (CSS) ASAM Level 3.5
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Community Support Program (CSP)
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Community Support Programs and Specialized Community Support Programs (CSP)
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Enhanced Acute Treatment Services (E-ATS) ASAM Level 3.7
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Inpatient Mental Health Services (IPLOC)
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Intensive Outpatient Program (IOP)
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Out of Network ECT Authorization Request
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Outpatient Behavioral Health Services
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Outpatient Electroconvulsive Therapy (ECT)
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Partial Hospitalization
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Psychological and Neuropsychological Testing
Repetitive Transcranial Magnetic Stimulation (rTMS)
Payment Policies
- Acupuncture Services
- Adjunct Professional Services Payment Policy
- Adult Day Health Payment Policy
- Adult Foster Care Payment Policy
- Allergy Testing and Immunotherapy
- Ambulatory Surgery Payment Policy
- Anesthesia Services
- Bilateral Procedures
- Bundled Codes
- Chiropractic Services
- Claims Reconsideration
- Clinical Trials
- Co-surgeon & Team Surgeon
- COVID-19 Services
- Dental Providers for Medical Reasons
- Dialysis
- Distinct Procedural Services (Modifier 59)
- Drugs and Biologicals
- Durable Medical Equipment (DME)
- Emergency Ambulance Services
- Evaluation and Management Services (Modifier 25)
- FQHC RHC
- Fraud, Waste, and Abuse
- General Coding Policy (Medicare Advantage)
- Global Days
- Home Health Care
- Home Infusion Therapy
- Hospice Services
- Hospice VBID Program
- Increased Procedural Services (Modifier 22)
- Individual Consideration Codes
- Inpatient and Intermediate/Diversionary Behavioral Health Services
- Laboratory & Pathology Services
- Modifier Policy
- Multi-function Home Ventilators
- Multiple Procedure Payment Reduction for Diagnostic Services
- Multiple Procedure Payment Reduction for Medical and Surgical Services
- National Drug Code Requirements
- Non-Physician Provider Payment Policy
- Nurse Practitioner/Physician Assistants (Medicare Advantage)
- Nursing Facility
- Observation Services
- Obstetric Anesthesia Services
- Opioid Replacement Therapy and Medication Assisted Treatment
- Ordering Provider NPI (National Provider Identifiers)
- Out-of-Network Provider Policy
- Outpatient Rehab
- Overpayment Policy
- Oxygen
- Prior Authorization
- Radiology Payment Policy
- Readmission Within 30 Days
- Re-bundling and NCCI Edits
- Reduced Services and Discontinued Procedures
- Robotic-Assisted Surgery Payment Policy
- Same Day/Same Service
- Serious Reportable Events (SRE)
- Skilled Nursing (Medicare Advantage)
- Telemedicine—Telehealth Policy
- T Status Codes Payment Policy
- Unlisted Procedure Codes
- Urine Drug Test
- Ventricular Assist Devices
- Vision Services