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  • Request For Claim Breview Formb - Commonwealth Care Alliance - Commonwealthcarealliance

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Request for Claim Review Form Please complete all required Information on the form below. Claim Review Forms submitted with incomplete information or insufficient documentation will be returned unprocessed.

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Commonwealth Care Alliance (CCA) One Care (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees.

Christopher D. Since 2015 as president and chief executive officer, Chris has transformed Commonwealth Care Alliance into a nationally leading $2 billion health system, which has consistently provided improved health and quality outcomes to its customer base.

Appeals need to be filed within 60 calendar days of the date on the denial notice you receive for a coverage determination or organization determination. CCA can accept an appeal beyond 60 days if good cause for an extension is shown.

Pharmacy Appeals You, your doctor, or an appointed representative have the right to file an appeal if we denied coverage for your prescription drugs. There are two ways you, your doctor, or an appointed representative may file a pharmacy appeal: Call us at: 866-610-2273 (TTY 711)

Compliance hotline: 844-762-5212. Email: FWAreferralsCA@commonwalthcare.org.

Release of Information (ROI) Form - Commonwealth Care Alliance. This form is used to release your health information from CCA to a person or organization. It can also be used to request your health information from a person or organization, such as a healthcare provider or hospital, to be shared with CCA.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232