Provider ManualMembersMember Rights StatementCommonwealth Care Alliance is committed to providing easily accessible, high quality services to our members. This objective is best met by establishing a mutually respectful relationship that promotes privacy, effective treatment, and member satisfaction. Contacting Our Member Services DepartmentMembers, potential members, and/or providers can reach Commonwealth Care Alliance's Member Services Department by calling: Toll Free: 1-866-610-2273 TTY: 1-866-322-7357 The Member Services Department is available Monday-Friday, 8 a.m.-6 p.m. Our staff members speak many of the same languages that our members speak, such as Spanish, Russian, Armenian, and Portuguese. To meet additional member language needs, Commonwealth Care Alliance utilizes a translation service. Commonwealth Care Alliance also provides after hours coverage and weekend contact, accessible by dialing the phone numbers listed above. The clinician on-call will answer and assist with any problems. Commonwealth Care Alliance is available 24 hours a day, 7 days a week. Commonwealth Care Alliance cares about the privacy of our members protected health information (PHI). Commonwealth Care Alliance will ask to verify a provider's identity prior to the release of any member information. Commonwealth Care Alliance asks that providers have their Commonwealth Care Alliance provider ID number or NPI number available each time they contact Commonwealth Care Alliance. Member Identification CardEach member receives a Commonwealth Care Alliance identification card to be used for services covered by this plan and prescription drug coverage at network pharmacies. Commonwealth Care Alliance's Senior Care Options (SCO) program covers the dual population as well as the MassHealth only population. In both scenarios, prescription drugs are a covered benefit. We must display the Medicare Rx symbol on the member card for dually eligible members, thus please be aware that we have two distinct member cards. Please see examples below: Dually Eligible Member Identification Card
1. Plan Name 2. Member Name, Date of Birth, Member ID number 3. Primary Care Physician (PCP) and Copays 4. Medicare Symbol (required by Medicare) 5. CMS Contract Number, Plan Benefit Package Number, Electronic Routing Information (for use by pharmacies) 6. Member Emergency Contact Info 7. Claim Submission Contact 8. Important Numbers, 24 hour/7 days access Please call Member Services at Commonwealth Care Alliance to verify eligibility and confirm that the membership is still active. Medicaid Only Member Identification Card
1. Plan Name 2. Member Name, Date of Birth, Member ID Number 3. Primary Care Physician (PCP) and Copays 4. Electronic Routing Information (for use by pharmacies) 5. Member Emergency Contact Info 6. Claim Submission Contact 7. Important Numbers, 24 hour/7 days access Please call Member Services at Commonwealth Care Alliance to verify eligibility and confirm that the membership is still active. Membership Verification ProcessCommonwealth Care Alliance strongly advises its contracted providers to verify Commonwealth Care Alliance membership whenever services are rendered. Eligibility information can be accessed in the following ways:
Virtual Gateway EVS System The Virtual Gateway is an internet portal designed by the Executive Office of Health and Human Services to provide the general public, medical providers, community-based organizations, and EOHHS staff with online access to health and human services. For more information about access methods, call the Virtual Gateway Customer Service at 1-800-421-0938. Primary Care Sites & Primary Care PhysiciansAll Commonwealth Care Alliance members must select a primary care site (PCS) and a primary care physician (PCP) at the time of enrollment. An Outreach & Marketing Representative will work with the member to ensure the selection of a PCS and PCP within Commonwealth Care Alliance's provider network. Primary Care Physician Commonwealth Care Alliance will contract with only licensed physicians who are willing and able to meet all of the following PCP requirements. The PCP must:
Request to Change Primary Care PhysicianA member may request a change in their PCP at any time by calling the Member Services Department. PCP changes within a PCS take place immediately. However, if the member requests to change the PCP to another location, the change will become effective the first day of the following month. Providers with general concerns or questions about PCP assignments may call Member Services. Health Care Proxies & GuardianshipsHealth Care Proxy Commonwealth Care Alliance strongly encourages its members to sign a Health Care Proxy (HCP) at the time of enrollment if the member does not have one prior to enrollment. Click here to download the HCP form.
1. The principal signs a subsequent HCP 2. The principal legally separates from or divorces the spouse who is named in the proxy as the agent 3. The principal notifies the agent, doctor, or other health care provider, orally or in writing that the principal wants to revoke the HCP 4. The principal does anything else that clearly shows he or she wants to revoke the proxy, for example, tearing up or destroying the proxy, crossing it out, telling other people, etc.
Guardianship A guardian is appointed when an individual is unable to make decisions for him or herself due to mental illness, mental retardation, or physical incapacity or illness. Some things to consider are:
Click here to download the guardianship decree. Commonwealth Care Alliance's Commitment to its MembersIndividualized Plan of Care The primary care team (PCT) develops an individualized plan of care (IPC) for each enrollee. The IPC describes the areas to be addressed and managed by the PCT in collaboration with the member and/or caregiver. The member or caregiver signs the IPC to indicate their participation in care planning activities. Click here to view a sample IPC. New Member Welcome Packet All new Commonwealth Care Alliance members receive a packet containing the following items:
New Member Welcome Calls Commonwealth Care Alliance members receive a welcome call from a Member Services Representative within 30 days of enrollment. Calls are conducted in the primary language of the member to ensure their full comprehension. Member Services Representatives reach out to members via telephone and through written communication to introduce Commonwealth Care Alliance and to explain how to access services. Some of the topics covered by the welcome call include:
Local Consumer Meetings Consumer participation and involvement are critical to Commonwealth Care Alliance's model of care and organizational identity. Since 2005, Commonwealth Care Alliance has held local consumer meetings for its members, their families, and caretakers to come together to share their thoughts and experiences of the program. The meetings give Commonwealth Care Alliance the opportunity to listen to members and ask for ideas on how to improve. Members are informed on issues including flu shots, rights to file complaints or grievances, and opportunities to participate in the Chronic Disease Self-Management program. Commonwealth Care Alliance also uses the meetings to answer questions members have about their coordination of health care needs. Local consumer meetings are a great place for members to meet one another and share experiences. It can be very comforting for members to learn there are others out there with similar challenges and concerns. Local consumer meetings are held in the communities where our Commonwealth Care Alliance members live, and are conducted in languages that those members speak. For more information, contact Commonwealth Care Alliance's Department of Health Education & Caregiver Training at (617) 426-0600. Complaints and Grievances Commonwealth Care Alliance is committed to ensuring member satisfaction. Upon the receipt of a member complaint, a representative of Member Services will record the information in the member complaint database. Commonwealth Care Alliance works to ensure timely resolution for all complaints. Members should hear from Commonwealth Care Alliance with a resolution no longer than 30 days from the date the complaint was filed. Once a member or member's representative has filed a complaint, Commonwealth Care Alliance will discuss it with the member or member's representative and explain the specific steps Commonwealth Care Alliance takes to resolve a complaint. This includes how long Commonwealth Care Alliance expects the process to take. During the complaint process, Commonwealth Care Alliance will continue to furnish the member with all services at the frequency provided in the current IPC. Providers are encouraged to help members file a complaint if asked.
Examples of complaints:
For more information regarding Complaints and Grievances, please read the Clinical Management section. Member Responsibilities and RightsCommonwealth Care Alliance providers must treat Commonwealth Care Alliance members with fairness, honesty and respect, including refraining from any biases based on income status, physical or mental condition, or English proficiency. Member Responsibilities Members are informed of their responsibilities on joining Commonwealth Care Alliance by receiving an Evidence of Coverage (EOC) handbook. Member responsibilities include, but are not limited to, the following:
Member Rights
For additional information about member rights and responsibilities, please call our Member Services Department. Please also call Member Services if there is reason to believe that a member has been treated unfairly or that the member's rights have not been respected. Additional Member Resources
Last Updated 3/15/12 |
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