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
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Notice of Privacy Practices
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Request for Claim Review Form
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FAQs: Prior Authorization Requests
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PA Form – Repetitive Transcranial Magnetic Stimulation Request
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PA Form – Psychological and Neuropsychological Assessment
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PA Form – Cardiac Imaging
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PA Form – CT/CTA/MRI
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PA Form – PET – PET CT
Download:
Standard Prior Authorization Request Form
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Claims Requirements
Claims Requirements 1500 Professional Form
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Claims Requirements UB Institutional Form
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CMS Provider Directory Requirements
Guidance to Verify Adequate Networks & Current Provider Directories
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Provider Directory Requirements
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