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(CCA) Provider Manual provides comprehensive administrative guidance for participating providers serving CCA Senior Care Options and CCA One Care members and patients. It explains the organization’s affiliation with CareSource, outlines program and plan information, policies and procedures, referral and claims resources, and key updates including the One Care transition to FIDE-SNP. The manual also details authorization requirements, eligibility and appeals, centralized enrollees records, billing workflows, clinical documentation and Medicare risk adjustment, coordination of benefits, pharmacy and provider training, plus forms, compliance, and fraud, waste & abuse 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4  \nSECTION 2: INTRODUCTION TO COMMONWEALTH CARE ALLIANCE ...................................................... 9  \nSECTION 3: MEMBER ELIGIBILITY, APPEALS & GRIEVANCES ................................................................. 10  \nSECTION 4: PRIOR AUTHORIZATION REQUIREMENTS ............................................................................... 19  \nSECTION 5: CENTRALIZED ENROLLEE RECORD .........................................................................................24  \nSECTION 6: CLAIMS AND BILLING PROCEDURES .......................................................................................25  \nSECTION 7: CLINICAL DOCUMENTATION AND MEDICARE RISK ADJUSTMENT ..................................41  \nSECTION 8: COORDINATION OF BENEFITS AND THIRD-PARTY LIABILITY............................................43  \nSECTION 9: PHARMACY PROGRAM ................................................................................................................ 45  \nSECTION 10: INFORMATION FOR ANCILLARY PROVIDERS—EXTENDED CARE FACILITIES, DURABLE MEDICAL EQUIPMENT & VISION ................................................................................................... 50  \nSECTION 11: BEHAVIORAL HEALTH SERVICES PROVIDERS .................................................................... 59  \nSECTION 12: LONG-TERM SERVICES AND SUPPORT PROVIDERS ......................................................... 79  \nSECTION 13: QUALITY IMPROVEMENT PROGRAM ...................................................................................... 81  \nSECTION 14: PROVIDER ENROLLMENT AND CREDENTIALING ................................................................90  \nSECTION 15: MARKETING GUIDELINES ........................................................................................................ 102  \nSECTION 16: COMPLIANCE AND FRAUD, WASTE & ABUSE PROGRAM ............................................... 104  \nSECTION 17: PROVIDER TRAINING ................................................................................................................ 113  \nSECTION 18: FORMS .......................................................................................................................................... 115  \nDear Provider,  \nWelcome to the 2026 Commonwealth Care Alliance, Inc. (CCA) Provider Manual. This manual serves as a guide and resource for you as we work together on behalf of the members and patients we mutually serve.  \nThis year has been one of great change both within CCA and across the entire healthcare landscape. Our most significant development has been CCA’s affiliation with CareSource, a nationally recognized, nonprofit managed care organization.  \nAs part of the CareSource family of companies, CCA’s members and patients continue to receive best-inclass, disability-competent care and coordination from their same care teams – enhanced and strengthened through shared resources and expertise to address the critical needs of members and the broader community. The linchpin in all of this is our robust network of providers – our valued partners who share our deep understanding of the complex needs of those we serve across the Commonwealth.  \nAs we look ahead to continued developments to better meet the needs of those we serve, I’d like to thankyou for your ongoing commitment to the populations in our CCA Senior Care Options and CCA One Care plans – all of whom are dual-eligible and often have multiple co-occurring conditions. Your partnership and collaboration are essential to achieving our mission of improving the health and well-being of those with the most significant needs.  \nOur provider manual is an administrative resource that provides comprehensive information about our programs and plans. It serves as a centralized location for much of the ","cbCaitvdE4fSkP9z","https://ap.wps.com/l/cbCaitvdE4fSkP9z","pdf",4887509,115,"English","# Section 1: Key Contact Information\n# Section 2: Introduction to Commonwealth Care Alliance\n# Section 3: Member Eligibility, Appeals & Grievances\n# Section 4: Prior Authorization Requirements\n# Section 5: Centralized Enrollee Record\n# Section 6: Claims and Billing Procedures\n# Section 7: Clinical Documentation and Medicare Risk Adjustment\n# Section 8: Coordination of Benefits and Third-Party Liability\n# Section 9: Pharmacy Program\n# Section 10: Information for Ancillary Providers\n# Section 11: Behavioral Health Services Providers\n# Section 12: Long-Term Services and Support Providers\n# Section 13: Quality Improvement Program\n# Section 14: Provider Enrollment and Credentialing\n# Section 15: Marketing Guidelines\n# Section 16: Compliance and Fraud, Waste & Abuse Program\n# Section 17: Provider Training\n# Section 18: Forms","[{\"question\":\"What is the purpose of the 2026 CCA Provider Manual?\",\"answer\":\"It serves as a centralized administrative resource providing comprehensive information about CCA programs and plans, including policies and procedures, referral and claims information, and other reference materials for participating providers.\"},{\"question\":\"What key update is included regarding the One Care plan?\",\"answer\":\"The manual includes an update on the transition of the One Care plan to a FIDE-SNP, along with changes to the State’s eligibility process and deeming periods.\"},{\"question\":\"How can providers contact CCA Provider Services for questions about the manual?\",\"answer\":\"Providers can contact the CCA Provider Services team at 866-420-9332, with hours listed for Monday, Tuesday, Wednesday, Friday (8 a.m. to 5 p.m. EST) and Thursday (8:30 a.m. to 5 p.m. EST).\"}]","Commonwealth Care Alliance 2026 Provider Manual | PDF",1792710788,290]