Forms and referrals
We want to make it easy to work together so our members, and your patients, have the best experience possible. Here you can access important provider forms and learn how to refer a patient to CCA.
Jump to: Administrative Forms & Notices | Prior Authorization Forms | Claims Requirements | CMS Provider Directory Requirements
Refer a Patient
Together we can create a better experience and better outcomes for your patients with complex needs.
Administrative Forms and Notices
Appointment of Representative (Form CMS-1696)*
Download:
2022 PA Select Drug Exception List
2022 Prior Authorization Requirements
Coverage Requests & Determination
2022 Durable Medical Equipment
Request for Claim Review Form
Download:
FAQs: Prior Authorization Requests
PA Form – Repetitive Transcranial Magnetic Stimulation Request (RI)
Download:
PA Form – Psychological & Neuropsychological Assessment (RI)
Download:
PA Form – Cardiac Imaging
Download:
PA Form – CT/CTA/MRI
Download:
PA Form – PET – PET CT
Download:
Standard Prior Authorization Request Form
Download:
CCA ECT Authorization Request
Download:
Claims Requirements
Claims Requirements 1500 Professional Form
Claims Requirements UB Institutional Form
CMS Provider Directory Requirements
Guidance to Verify Adequate Networks & Current Provider Directories
Download:
Provider Directory Requirements
Download:
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