Billing Manual for Community Care Network Providers

APPENDIX A.2. Confidentiality 130APPENDIX A.3. Supplemental Confidentiality 157APPENDIX A.4. Significant Member Incidents 198APPENDIX B.1. Consents for Release of Information Forms and forPhysical Health/Behavioral Health Collaboration 201APPENDIX C.1. Priority Populations 208APPENDIX D.1. Behavioral Health Managed Care Organizations (BH-MCOs)Performance/Outcome Management System (POMs) 211APPENDIX E.1. Companion Guide for Northeast Counties 216APPENDIX F.1. Companion Guide for North Central Counties 217Community Care Member Handbooks Can Be Assessed At:www.ccbh.com/healthchoices/memberhandbookCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 5

such as seafood processing, forestry, hospitality, landscaping, construction and agriculture.These industries are all critical to overall economic health across the American South. Manyof these businesses have been hit hard by the economic downturn, and governments at the stateand federal levels must do all that they can to support these businesses so that they are notforced to further reduce their workforce. Therefore it is essential that wages for H-2B workersremain in line with the economic realities faced by these businesses, which often operate onextremely thin profit margins. Southern Governors are concerned that changes to themethodology for calculating wages, as proposed by the Department of Labor (DOL), wouldincrease wages to the extent that they are no longer reflective of economic realities, and wouldresult in a significant loss of jobs in these industries as companies are forced into bankruptcy.As DOL contemplates changes to the wage methodology, it should consider the economicpressures faced by these industries, and provide ample time for businesses to prepare for anychanges to the wage methodology.• Locate a satellite U.S. Patent and Trademark Office in the American South—Therecently passed America Invents Act includes authorization for four new U.S. Patent andTrademark satellite offices across the nation. Southern Governors strongly urge placement ofat least one of those offices in the American South. With over 40 percent of the U.S.population and nearly a quarter of the nation's landmass, the American South is a region whereinnovation happens. Southern Governors are strongly committed to creating an environmentthat supports private sector innovation, and our states already stand out on a wide range offactors that are fundamental to a strong innovation ecosystem, including global engagement, arobust research environment, and scientific and technically knowledgeable residents. Withtalented and dynamic people and organizations, a strong commitment to science, technology,education, research, and business development, and a long history of public-privatecooperation, the American South represents an excellent choice in which a USPTO satelliteoffice should be located.

Clinical Fax by County:Adams 1-866-418-0366 Allegheny 1-888-251-0087 Berks 1-866-418-0366Blair 1-855-473-2359 Bradford 1-866-294-3935 Cameron 1-866-294-3935Carbon 1-866-901-8367 Centre 1-866-294-3935 Chester 1-888-589-6559Clarion 1-866-294-3935 Clearfield 1-866-294-3935 Clinton 1-855-473-2360Columbia 1-866-294-3935 Elk 1-866-294-3935 Erie 1-855-892-8495Forest 1-866-294-3935 Huntingdon 1-866-294-3935 Jefferson 1-866-294-3935Juniata 1-866-294-3935 Lackawanna 1-866-284-9184 Luzerne 1-866-284-9184Lycoming 1-855-473-2360 McKean 1-866-294-3935 Mifflin 1-866-294-3935Monroe 1-866-901-8367 Montour 1-866-294-3935 Northumberland 1-866-294-3935Pike 1-866-901-8367 Potter 1-866-294-3935 Schuylkill 1-866-294-3935Snyder 1-866-294-3935 Sullivan 1-866-294-3935 Susquehanna 1-866-284-9184Tioga 1-866-294-3935 Union 1-866-294-3935 Warren 1-866-294-3935Wayne 1-866-294-3935 Wyoming 1-866-284-9184 York 1-866-418-0366TTY for people who are Deaf/Hard-of-Hearing 1-877-877-3580Spanish Line 1-866-229-3187Autism Support Line 1-866-415-1708PA Child Abuse Hotline 1-800-932-0313Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 7

Guidelines for Obtaining Approval for In-Plan and Supplemental ServicesMental HealthServiceEmergencyEvaluationCrisis Services:Mobile, Telephone,Walk-InPsychiatricOutpatientEvaluation or InitialNon-MD evaluationBest Practice / LifeDomain Evaluation 2AuthorizationTypeNotification viaFacsimileTransmittalRequest FormNoneNotification;ApprovedBHRSCAProviders andBHRSCAprescriberssubmit viaFacsimileTransmittalRequest FormLimits/Exclusions/DefinitionsHospital not reimbursed separately if patient isadmitted within 24 hours to the evaluating facility.Fax within 60 days after service.Child: State-approved Best Practices format isrequired for Behavioral Health Rehabilitation Servicesfor Children and Adolescent (BHRSCA) services andRTF.In some parts of the Commonwealth there is verylimited access to licensed psychologists and nonlicensedproviders sometimes complete evaluationswithout any face-to-face evaluation by the licensedpsychologist. Community Care will allow this practiceto continue. However, we encourage licensedprescribers to continue to participate in all BestPractice evaluations and re-evaluations unless accessissues make that option impossible.Please note that, if doctoral or master's levelclinicians who are non-prescribers are conducting partsof or the entire BP evaluation, these individuals mustbe designated by and directly supervised by thelicensed prescriber. Please refer to Chapter 41 of thePA Code for Psychologists by the State Board ofPsychology.Community Care advocates that prescribers review thecase w/the doctoral or master’s level clinicians who areconducting parts of or the entire evaluation. RequestForm must be submitted following the initial evaluation;not to exceed the timely filing limits for Claimssubmission for the member’s product coverage.Concurrent: Request Form must be submittedfollowing the updated evaluation Request; not toexceed the timely filing limits for Claims submission forthe member’s product coverage.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 8

Outpatient Therapy 1MD OutpatientMedication CheckRN OutpatientMedication Check 1ServiceCoordination:Intensive CaseManagement/ResourceCoordination/Blended CaseManagementFamily-BasedMental HealthServicesAnnualRegistrationOnlyNone —AnnualRegistrationOnlyNotification viaFacsimileTransmittalRequest FormPrecertificationInitial: Registration must be submitted following theinitial outpatient visit; not to exceed the timely filinglimits for Claims submission for the Member’s productcoverage.Concurrent: Registration must be submitted prior tothe expiration of the initial annual registration period;not to exceed the timely filing limits for Claimssubmission for the member’s product coverage.REFER TO THE BILLING SECTION FOR TIMELYFILING LIMITS FOR EACH HEALTHCHOICESPRODUCT.Initial: Registration must be submitted following theinitial outpatient visit; not to exceed the timely filinglimits for Claims submission for the member’s productcoverage.Concurrent: Registration must be submitted prior tothe expiration of the initial annual registration period;not to exceed the timely filing limits for Claimssubmission for the member’s product coverage.REFER TO THE BILLING SECTION FOR TIMELYFILING LIMITS FOR EACH HEALTHCHOICESPRODUCTUnit definition: 1 unit = 15 minutes.Initial: Registration must be submitted within 30 daysof the initial evaluation.Concurrent: Registration must be submitted within 30days before or after the current authorization end date.Unit definition: 1 unit = 15 minutes.Providers send/fax precert to their designated caremanager who reviews and, if case meets medicalnecessity for the service, authorizes. The standardreview schedule is to complete a Continued StayReview at month 3 then again at month 6. The finalreview (Discharge Review) is completed within 5business days of discharging the client from treatment.Of note, care managers always reserve the right toauthorize and schedule reviews at their discretionbased on such concerns as poor progress in treatmentor high risk cases that require more care managerinvolvement and/or more frequent review.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 9

PsychologicalTesting/NeuropsychologicalTestingElectroconvulsiveTherapyNon-Acute PartialHospitalizationPrecertification;FacsimileTransmittalRequest FormPrecertificationfor OutpatientonlyNotification;FacsimileTransmittalRequest FormTelephonicPrecertificationPrecertificationChild or Adolescent: Authorized by testing group,peer review.Adult: Authorized by test, peer review.Peer review.Limit of 3 hours minimum to 6 hours maximum per day.Acute PartialLimit of 3 hours minimum to 6 hours maximum per day.HospitalResidentialBased on clinical necessity.Treatment FacilityRe-evaluation required every 90 days.Behavioral Health Precertification Authorized by specific procedure; Community CareServices (BHRS) 2 planning team meetings.Rehabilitativecare manager to be invited to all interagency serviceInpatient AdmissionClozaril(Monitoring/Evaluation and SupportServices) 1PsychiatricRehabilitation; Site-Based, Mobile,ClubhousePeer SupportMulti-systemicTherapy (MST)Precertificationexempt forMedicarePrimaryAnnualRegistrationOnlyPrecertification;FacsimileTransmittalRequest FormNotification;FacsimileTransmittalRequest FormMailPacket is due one week after the ISPT meetingBased on medical necessity criteria.Requires diagnoses on all 5 Axes; no V-codesNotification of admissions and within 30 days ofdischarge for Medicare Primary.Initial: Registration must be submitted following theinitial outpatient visit; not to exceed the timely filinglimits for claims submission for the member’s productcoverage.Concurrent: Registration must be submitted prior tothe expiration of the initial annual registration period;not to exceed the timely filing limits for claimssubmission for the member’s product coverage.REFER TO THE BILLING SECTION FOR TIMELYFILING LIMITS FOR EACH HEALTHCHOICESPRODUCTBased on clinical necessity.Initial: Two months authorized at pre-certification.Continued Stay: Three months authorized atcontinued stay.Unit definition: 1 unit = 15 minutes.Members must be age 18 or older or age 22 if inSpecial Education.Maximum six months authorized for each request.Packet is due one week after the ISPT meeting.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 10

Functional Familytherapy (FFT)MultidimensionalTreatment FosterCare (MTFC )Mobile MentalHealth Treatment(MMHT)Tobacco/SmokingCessationMailMailNotification;FacsimileTransmittalRequest FormNonePacket is due one week after the ISPT meeting.Packet is due one week after the ISPT meeting.Members must be age 21 or older.Maximum 30 units per 90 day authorization time frame.Based on clinical necessity and will be reviewed every90 days.Individual and group delivery.Maximum 70 units per year, per member/provider. Themaximum unit is calculated by the total number ofcombined units (individual and/or group).1Outpatient registration (OPR): Annual registration of Member required2 Includes mental health, mental retardation, and chemical dependency servicesCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 11

Guidelines for Obtaining Approval for In-Plan and Supplemental ServicesChemical DependencyServiceEmergencyEvaluationPsychiatricOutpatientEvaluation orInitial Non-MDEvaluationOutpatientTherapy 1MethadoneMaintenance(Outpatient) 1IntensiveOutpatientTherapyAuthorizationTypeNoneAnnualRegistrationOnlyAnnualRegistrationOnlyNotification viaFacsimileTransmittalRequest FormLimits/Exclusions/DefinitionsFor a hospital, not reimbursed separately ifpatient is admitted within 24 hours to theevaluating facility.Initial: Registration must be submitted followingthe initial outpatient visit; not to exceed timelyfiling limits for claims submission for themember’s product coverage.Concurrent: Registration must be submittedprior to the expiration of the initial annualregistration period; not to exceed the timely filinglimits for claims submission for the member’sproduct coverage.REFER TO THE BILLING SECTION FORTIMELY FILING LIMITS FOR EACHHEALTHCHOICES PRODUCTUnit definition:Bundled = 1 week (methadone and treatment)Unbundled = 1 day (methadone only)Initial: Registration must be submitted followingthe initial outpatient visit; not to exceed the timelyfiling limits for claims submission for themember’s product coverage.Concurrent: Registration must be submittedprior to the expiration of the initial annualregistration period; not to exceed the timely filinglimits for claims submission for the member’sproduct coverage.REFER TO THE BILLING SECTION FORTIMELY FILING LIMITS FOR EACHHEALTHCHOICES PRODUCTMust meet PCPC or ASAM for adolescents;service is minimum of 5.0 and maximum of 9.75hours per week.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 12

Non-Acute PartialHospitalizationNotification viaFacsimileTransmittalRequest FormPrecertificationMust meet PCPC or ASAM for adolescents; atleast 3 visits per week with a minimum of 10hours per week.Acute PartialHospitalizationMust meet PCPC or ASAM for adolescents; atleast 3 visits per week with a minimum of 10hours per week.Halfway House Precertification Must meet PCPC or ASAM for adolescents forMedicallyManagedRehabilitationNon-HospitalResidentialRehabilitation (3B;short-term or 3C;long term)MedicallyManagedDetoxificationNon-HospitalDetoxificationDrug & AlcoholCaseManagement(ICM/RC)Drug & AlcoholLevel of CareAssessmentPrecertificationPrecertificationlevel 2B.Must meet PCPC or ASAM for adolescents forLevel 4B.Requires diagnoses on all 5 Axes; no V-codes.Must meet PCPC or ASAM for adolescents forlevel requested.Precertification Must meet PCPC for Level 4A.Requires diagnoses on all 5 Axes; no V-codes.Precertification Must meet PCPC for Level 3A.Notification;FacsimileTransmittalRequest FormNotification;FacsimileTransmittalRequest FormUnit definition: 1 unit = 15 minutes.Intake only – Maximum 8 units of service.Ongoing - Maximum of 300 units for a six monthtime frame.Unit definition: 1 unit = 15 minutes.Maximum of 8 units of service.1Outpatient registration (OPR): Annual registration of Member requiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 13

I. About Community Care Behavioral Health OrganizationCommunity Care is a federally tax-exempt Pennsylvania nonprofit and 501 (c)(3)behavioral health managed care organization (BH-MCO). We are subsidiary of UPMCand part of the UPMC Insurance Services Division.Licensed as a Pennsylvania risk-assuming PPO by the Pennsylvania InsuranceDepartment, Community Care manages behavioral health services for MedicalAssistance beneficiaries who live in the counties served by Community Care. Thisincludes members of the HealthChoices program in each of the regions, Southwest,Southeast, Capital-Lehigh, Northeast, and North Central (State and County options).Community Care contracts with providers (individual or group practitioners, or facilitiesor organizations) to offer diverse behavioral health (mental health and chemicaldependency) services to HealthChoices members.For the success of our partnerships with members, providers, and the communities weserve, as well as for the achievement of our goals, Community Care relies on the strongcommitment of all parties involved to conduct business lawfully and ethically.Community Care’s code of ethics is embodied in our mission statement, statement ofvalues, and code of conduct.These documents guide our interactions with all of our partners, stakeholders and eachother. Consistent with our code of ethics, Community Care has developed qualitymanagement programs, policies, and procedures to ensure compliance with legal,regulatory, and professional requirements.The following sections describe Community Care’s ethical framework and processes indetail:A. Code of EthicsB. Cultural Competency VisionC. Overview of Quality ManagementD. Compliance with Fraud and Abuse ReportingE. Care Management TeamCall the Provider Line at 1-888-251-2224 with questions about Community Care’sethical framework or other material in this manual.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 14

I.A. Code of EthicsCommunity Care’s code of ethics includes our Mission Statement as well as thefollowing statement of values.Statement of ValuesCommunity Care holds the following values: Maintain member health and well-being as our highest priority. Be responsive to the needs of all members. Serve as a vital resource and partner for the region and communities in which wework. Value member satisfaction among our highest priorities and strive to ensure acompassionate, member-centered environment. Use professional ethics and integrity, which we believe are vital in making soundbusiness decisions. Be accountable to the citizens of our regions in all of our work. Commit to a continuous quality improvement process that focuses on the highestlevel of customer satisfaction possible. Facilitate improvements in access to care and to provide optimal value for the dollarsavailable. Link assessments and outcomes to the decision-making process by means of thelatest clinical and information technology. Provide a culturally competent workplace that encourages employee growth andpromotes employee satisfaction. Appreciate the diversity of our members, families, communities, providers, and staff. Build on the strengths of members, families, and communities by encouragingmembers and their families to participate at all levels of nationally recognizededucation and prevention programs. Respect and uphold the traditions of the communities of which we are a part.I.B. Cultural Competency VisionIn 2000, Community Care developed the following Cultural Competency statement, withinput from a group of network providers, community representatives, and oversightentities.Our vision for an effective and accessible behavioral health system of care leads withhigh-quality services that improve the health and well-being of our community. Our goalis to offer a system, ultimately free of barriers to obtaining services, comprised ofintegrated, balanced, and responsive mental health and substance abuse care. It isbased on the Pennsylvania Call for Change: toward a Recovery-Oriented Mental HealthService System, which defines “recovery” as:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 15

“A self-determined and holistic journey that people undertake to heal and grow.Recovery is facilitated by relationships and environments that provide hope,empowerment, choices and opportunities that promote people reaching their fullpotential as individuals and community members.”It includes consumer choice, self-determination, and acceptance, and is designed toreach individuals and families at risk of crisis or disability; stimulate, facilitate, andsupport recovery for persons with behavioral health disorders; enable recovery; andpromote individual, family, and community health and well-being.To help Community Care representatives (including providers) understand andparticipate in Community Care’s vision, we share these definitions: Culture is the patterns of behavior that include communications, actions, customs,beliefs, values, and institutions of a social group. Cultural Identity includes, but is not limited to race, ethnicity, language, age, regionor country of origin, degree of acculturation, gender, socioeconomic class, religiousbeliefs, and gender. Cultural Awareness is the understanding that people are shaped by the social,linguistic, ethnic, and behavioral characteristics of the cultures to which they belongand that there are patterns of expressions, beliefs, values, and practices that can beshown to enable those providing behavioral health care to understand the diversityof people. Cultural Sensitivity is knowledge about the social, linguistic, ethnic, behavioral andinteractional characteristics of a group or population, how those behaviors andcharacteristics may influence a group’s worldview and the demonstration of thisknowledge through provider and organizational interactions and communications. Cultural Competence is the ability to systematically translate knowledge andunderstanding of the social, behavioral, and interactional differences of groups intoattitudes and practices of care, such as acknowledgment, inclusion, and helpfulnessthat promote the behavioral health and well-being of individuals, families, andcommunities.Cultural competence is an essential part of this vision. It benefits Community Care’snetwork of behavioral health providers by generating trust and maintaining credibilitywith members, agencies, and the community. Cultural competence demonstrates acommitment to eliminating barriers that prevent our agencies from meeting theirpotential and full responsibilities to their communities. That commitment is proventhrough effective policies and administration, effective frontline provision of services,and the evaluation of those services.Providers will be informed (through mailings, website articles, forums, and otherinteractions) about Community Care’s commitment to a culturally competent system ofservices provision, instructed on standards and performance indicators, providedexamples for demonstration of cultural awareness and sensitivity, given assistance andCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 16

esources and evaluated on their progress toward cultural competence. Providers’commitment is essential to our ongoing development of a responsive system of care.I.C. Overview of Quality ManagementThe Community Care quality management program is based on a philosophy thatemphasizes a systematic, organization-wide perspective that involves everyone. It isfocused on achieving satisfaction for both internal and external customers andimproving member outcomes within an organizational environment that seekscontinuous improvement of systems and processes.The foundation is good business ethics. Professional integrity and mutual respect aredefining characteristics of the quality management program philosophy.From its outset, Community Care recognized company-wide quality goals that havebeen integrated into all department activities. At its most fundamental level, qualitymanagement aims to sustain and improve the health status of members by measuringand improving performance of care and services within the healthcare delivery systemprocesses and structure. Community Care is committed to improving the health statusof the populations it serves and, by extension, the community. Our quality improvementprogram is designed with input from network practitioners and follows the guidelines ofall regulatory and oversight agencies including the Department of Health and theNational Committee for Quality Assurance (NCQA).Areas of focus include: Delivering high-value, culturally competent care that incorporates the special needsand preferences of members. Continuously improving the clinical care and service provided to members. Enhancing the community’s health status through behavioral health wellness andpreventive programs. Pursuing opportunities to improve the health status of members and target efforts tothe needs of the population. Ensuring that care and services are available and are provided to members in atimely manner, appropriate to the member’s needs and preferences. Ensuring that care and services are coordinated between providers and across alldelivery settings through the care management process. Establishing collegial relationships with providers to achieve superior clinical andcustomer service outcomes. Providing exceptional customer service. Continuously improving quality improvement processes by maintainingcomprehensive, current, and effective quality management policies and procedures. Analyzing performance data and identifying opportunities to improve performanceand outcomes.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 17

High-quality culturally competent health care and responsive customer services areprovided to all members. This philosophy is consistent with principles of continuousquality improvement as articulated by Deming, Juran, and others.Community Care views quality as an integrated company responsibility (promoted byspecific indicators facilitated by the Quality Management Department). CommunityCare's Board of Directors, management, departments, committees, oversight entities,providers, and community representatives all participate in quality improvementactivities.Community Care believes that input from appropriate committees, members, providers,and other stakeholders must be solicited on an ongoing basis in order for our qualityefforts to be successful.The philosophy stresses the importance of staff to achieve success. Teams ofindividuals are responsible for monitoring customer satisfaction and improvingperformance. Creativity and innovation within the scope of work are encouraged toensure customer satisfaction and exceed client and member expectations. Staff issupported in efforts to continually improve performance. Community Care views staff asthe solution to problems, not the cause. Community Care holds that the root causes ofsub-optimal performance, problems, or variation in a process are usually related to thesystem or process itself and not to staff.Community Care will share information with network providers about our: Quality improvement program, including goals, processes, and outcomes as relatedto care and service. Efforts to measure the availability of practitioners, facilities, and treatment programsand actions taken to improve availability. Efforts to measure the accessibility of care and service for members and actionstaken to improve accessibility. Overall findings of member satisfaction activities (such as the annual MemberSatisfaction Survey), including what we do to improve member satisfaction. Clinical practice guidelines and processes that measure guideline adherence. Expectations for exchange of information with primary care physicians (PCPs) andwithin the behavioral health continuum to facilitate continuity and coordination ofcare. Medical necessity criteria, including how to view or obtain a copy. Availability of and process for contacting the appropriate Community Care peerreviewer to discuss utilization management decisions. Description of the availability of an independent external appeals process forutilization management decisions made by Community Care. Policy prohibiting financial incentives for utilization management decision-makers. Member rights and responsibilities statement.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 18

Confidentiality policies including our routine uses and disclosures of enrollees’protected health information (PHI), enrollees’ rights to approve the release of PHInot covered by the routine consent, and access to the enrollees’ medical records.Preventive behavioral health programs including how successful these programshave been.Treatment record policies regarding confidentiality of treatment records,documentation standards, systems for organization of treatment records, standardsfor availability of treatment records at the practice site, and performance goals.If you would like more information regarding our quality improvement program, contactus at 1-888-251-2224. We will provide you with a description of the program and anupdate on our progress toward meeting our goals.If you have any suggestions for improving our quality improvement program or if youhave any questions about this information, please contact us:Community Care Behavioral Health Organization112 Washington PlaceOne Chatham Center, Suite 700Pittsburgh, PA 15219I.C.1. Quality Improvement MethodologyCommunity Care uses many processes in our quality management activities. A clearunderstanding of processes and knowledge of the reason for performance levels areessential to the quality management program. In order to understand performance, theinterdependent processes must be clear. Processes are related both hierarchically andin a matrix with many interrelationships. Until performance is measured using a rigorousmethodology, the actual state is unknown. Once a baseline is established, performancecan be understood in quantifiable terms. It is either out of control, in control but notwithin limits, or in control and within limits. Continuous improvement aims at havingperformance consistently at optimal achievable levels.Measurement with disciplined rigorous methodology is a principle strategy of the qualitymanagement program. This structured, disciplined operating orientation focuses onlong-term continuous improvement, recognizing that there are no quick fixes. Decisionsare based on fact and actual performance data, not opinions and anecdotal evidence.Quantitative methods are the foundation of the information used in making decisions.Measurement and performance data are fundamental to the quality managementprogram.The improvement system is continuous and consistent throughout the organization. Thecontinuous improvement system employs methodology for problem-solving, actionplanning, and performance improvement. The most commonly used problem-solvingmethodology is the “plan, do, check, act” method (the Shewhard-Deming cycle).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 19

I.C.2 MeasurementExplicit, well-defined critical performance measures are the essential component ofCommunity Care's quality management program. Critical performance indicatorsrepresent what is most important to Community Care in defining quality. They aredeveloped using sound methodological principles. The performance data that resultfrom measurement are reliable so that decisions can be made with confidence.Measurements are specifically defined in Community Care’s quality assurance WorkPlans. Each topic includes the measurements, goals, and timing of each activity. On anannual basis, Community Care publishes the results of Work Plan monitoring activitiesand studies in our communications. Interventions and results are also described.I.C.3 Record ReviewCertain measurements in Community Care’s annual Quality Management Work Planrely upon data collection through confidential record review. Selected network providersare contacted in advance of a record review. Areas of focus include topics such asaccessibility to covered services, appointment availability, coordination of care, qualityof care, and record keeping. Community Care expects providers to agree to furnishpertinent sections of an enrollee’s medical records, consistent with appropriate rules ofconfidentiality for patient records as described in the Network Provider Agreement andas specifically required by HealthChoices.I.C.4 Quality Management Program StructureThe quality management program description describes the structure and processes ofthe quality management program. The Work Plan lists the activities that comprise thequality management program. The Quality and Care Management Committee (QCMC)oversees implementation of the program and Work Plan.The quality management program is designed to continuously improve performance andprovide members with high-quality, cost-effective healthcare services, access andavailability to culturally competent healthcare providers and services, continuity andcoordination of care across all heath care delivery settings, and effective behavioralhealth prevention programs and health education services.I.C.5 Availability StandardsCommunity Care monitors availability by category of service, through its GeoAccessreporting capabilities, to ensure access to a Provider:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 20

Within 30 minutes for urban areas.Within 60 minutes for rural areas.These measures are included in the Quality Management Work Plan.I.C.6 Accessibility StandardsCommunity Care monitors access to routine, urgent, and emergent appointments:A routine request for an appointment met within seven days.An urgent request for an appointment met within 24 hours.A non-life-threatening request met within one hour.A life-threatening emergency met immediately.These measures are included in the Quality Management Work Plan. Refer to SectionIV.D. for more information about accessibility.I.D. Compliance with Fraud and Abuse ReportingTo fulfill our mission and to act in accordance with our values, code of conduct, andpolicies, Community Care monitors and investigates suspected fraud and abuse,defined as follows:Fraud is an intentional deception or misrepresentation made by a person with theknowledge that the deception could result in some unauthorized benefit to him orsome other person. Examples of fraud could include a provider submitting a bill for aservice that did not occur, billing for a time period greater than the time actuallyspent with the client, billing for provision of a service that did not meet the servicedefinitions, billing or charging Medical Assistance recipients for covered services,billing more than once for the same service, or dispensing generic drugs and billingfor brand name drugs.Abuse by a provider is defined as provider practices that are inconsistent with soundfiscal, business, or medical practices and result in unnecessary costs or inreimbursement for services that are not medically necessary or that fail to meetprofessionally recognized standards for health care. "Abuse" also includesCommunity Care member practices that result in unnecessary costs.Community Care monitors for possible fraud and abuse within our provider network byconducting audits, investigating fraud, waste, and abuse (FWA) referrals, and analyzingbilling and payment data. When suspected fraud or abuse is identified, Community Carereports these occurrences to appropriate licensing, reporting, and investigative agenciesand takes appropriate action to prevent future fraud or abuse.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 21

I.D.1 Procedures for Suspected Fraud or AbuseAny Community Care staff member suspecting fraud must report the suspicion, either tohis or her supervisor or directly to Community Care's Fraud and Abuse Department. Thereport can be made via the Fraud and Abuse Hotline at 1-866-445-5190, e-mailed toCCBH_Fraud_Abuse@upmc.edu, or by submitting an internal referral to the Director orManager of the FWA Department. If the supervisor is notified first, he or she must reportthe suspicion to the Director of Fraud and Abuse within one business day of receivingthe staff member's report.Consequences of confirmed fraud include repayment of monies paid for the fraudulentclaims and the requirement to submit a corrective action plan that outlines how the auditexceptions will be prevented in the future. Notification of the identified fraud incident willbe sent to the Department of Public Welfare, Bureau of Program Integrity (DPW/BPI),the appropriate county administrators, and the county oversight entities. Suspension orexclusion from the Community Care network of providers may also occur as a result ofthe fraudulent activity.I.D.2 Avoiding Fraud and AbuseCommunity Care encourages providers to read this Provider Manual and/or call theProvider Line (1-888-251-2224) with any questions about standards of care,documentation and record keeping, claims/billing procedures, or any other activity thatcould be associated with a fraud or abuse concern. In addition, Community Care offersprovider training on these and other topics.I.D.3 Reporting Suspected Fraud and Abuse to the Department of Public WelfareThe Department of Public Welfare has established a hotline to report suspected fraudand abuse committed by any entity providing services to Medical Assistance recipients.The hotline number is 1-866-DPW-TIPS (1-866-379-8477) and operates between thehours of 8:30 a.m. and 3:30 p.m., Monday through Friday. Voice mail is available at allother times. Callers may remain anonymous and may call after hours and leave a voicemail if they prefer.Suspected fraud and abuse may also be reported via the DPW website at:http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/maprovidercompliancehotline1866dpwtips/index.htmInformation reported via the website can also be done anonymously. The websitecontains additional information on reporting fraud and abuse.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 22

I.E. Care Management Team“Advocates” is a word often used by others to describe Community Care’s caremanagement team because of their attention to quality, clinical effectiveness, memberchoice, and the recovery philosophy. This clinically focused team was created early inCommunity Care’s history—as the means to effectively assist members in makinginformed decisions about the services and supports that are available to them and toassist providers in quality service delivery through consultation and collaboration. Caremanagement focuses on:Adult mental health services.Services for children and adolescents.Drug and alcohol services.Dual diagnoses services.Service Precertification.Members identified as high risk.Care management uses diverse resources and team member expertise to ensure thatassistance is available to members and providers whenever needed.Care management operates 24 hours a day/seven days a week, with clinicalsupervisors on call at all hours. All care management staff have direct access toCommunity Care’s Professional Advisor staff, 24 hours a day. Care management worksclosely with other departments in Community Care, such as network management,information systems, quality management, and credentialing. In addition, CommunityCare’s prevention, outreach, communications, and training teams support members andproviders in other ways.The purpose of the care management team is to:Ensure that services are medically necessary and are being delivered at theappropriate intensity for a prescribed length of time with member participation as apart of the treatment team.Ensure coordinated care for all services and supports that the member is receivingand follow up care as a member is transitioning from one level of care to another.Monitor the quality of care in several ways, including review of treatment documents,attendance at team meetings, member and provider feedback, and analysis ofutilization information.Provide a responsive complaint and grievance process that ensures members canvoice their opinions about the care, services, and information they receive.Be available to answer questions from members and providers.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 23

It is common for Community Care’s care managers to attend treatment team meetings,to work with groups of providers and other stakeholders in specialty areas to improvethe quality of care, and to design trainings in areas where education is requested and/orneeded. Care Managers work with members, families, providers, and others; often incommunity settings.I.E.1 Adult Mental Health, Substance Use, and Dual Diagnoses ServicesAn important function of care management is to ensure coordinated care and follow up.This is especially important when members are unfamiliar with treatment andcommunity support options. Care managers are committed to ensuring that eachindividual member has the tools needed to move forward in the recovery process.Care managers are looking for:Appropriate clinical information including discussion of treatment options with themember and/or family.The consideration of non-traditional services such as Psychiatric Rehabilitation,Diversion and Acute Stabilization, Enhanced Clinical Case Management, AcuteCase Management and Community Treatment Teams (CTT) as well as Recoveryand Peer Supports.Proactive discussion, planning, and documentation of strategies for members toutilize when dealing with crisis situations.Effective provider collaborative efforts focused on diverting members from the mostrestrictive levels of care and increasing community tenure.Identification of a need for workgroup meetings with providers, members, and otherstakeholders to establish consistent “best practices” for specific levels of care.Care managers act as consultants to the treatment team when requested. They alsoclosely monitor:Overall access to services within designated time and distance standards and gapswith needed services.The geographic make-up of the provider network ensuring a diverse network ofoptions for members.The appropriate application of Medical Necessity Criteria (MNC) and properdocumentation of supporting information for the purpose of utilization management.Coordination of care activity between behavioral health and physical healthproviders.Inquiries, complaints, and strategies to assist members with multiple and/or complexneeds.The extent to which members with a co-occurring disorder receive referrals forservices and supports that fully address their needs.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 24

In order to serve special population groups and members with high utilization of themost restrictive levels of care, a “tier” methodology is utilized to identify members whomay require special intervention by a care manager. All members have a specific caremanager assigned to them.Team members work collaboratively to serve members that have been duallydiagnosed. Mental Illness/Substance Abuse (MISA) screenings have become part of aformal program for members who are receiving both mental health and drug and alcoholservices. Care managers ask questions during regular utilization reviews to determinewhether providers are screening for dual disorders and offering appropriate referrals tomembers when a co-occurring disorder is identified. The program is monitored on anongoing basis through quality record reviews.I.E.2 Services for Children and AdolescentsCommunity Care’s child and adolescent team is a specialized group of care managerswith a strong background and expertise in the areas of child and adolescent services aswell as family systems. These care managers collaborate with providers and childrenand their families in reviewing options for treatment, coordinating services, and ensuringtimely access to needed services.These care managers:Provide parents with specific information.Monitor the prescription of services and actual service delivery for each child.Attend interagency team meetings.Monitor Behavioral Health Rehabilitative Services for Children and Adolescents(BHRSCA) through active participation with the treatment team.Monitor Residential Treatment Facility (RTF) services with an emphasis on transitionplanning.Ensure coordination of care between behavioral health providers and with thePrimary Care Physician.Ensure proper involvement of children/family services agencies or juvenile justiceagencies when needed.Facilitate coordination with schools.Facilitate physical health and behavioral health Integrated care.Consider non-traditional services such as therapeutic services in MultidimensionalTreatment Foster Care (MTFC), Multisystemic Therapy (MST) and Functional FamilyTherapy (FFT).Act as consultant to the treatment team when requested.Community Care also provides written informational material for parents, includingprevention program materials and information about Community Care’s Family AdvisoryCommittee events.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 25

I.E.3 Pre-certification TeamCommunity Care maintains a dedicated team of care managers to conductprecertification reviews for acute levels of care. These care managers ensure thatindividuals’ needs and strengths have been assessed, that the specific level of carerequested meets MNC and that the requested level of care provides the least restrictiveenvironment for the member to continue the recovery process. In addition, the caremanagers on the precertification team may assist the member and provider inidentifying options and facilitating diversion planning. These care managers will alsofacilitate coordination of care efforts based on the member’s treatment history, currentauthorized services and active crisis plan.I.E.4 High Risk InterventionThis specific team of care managers works with members and their providers to resolvecomplex or high risk factors which impact the member’s ability to progress towardsrecovery. Face to face or telephone contact is focused on both the member andprovider. Because medical conditions often co-exist with a behavioral health diagnosis,coordinating care with physical health practitioners is also a priority.This team’s activities are driven by the needs and strengths of the individual memberwith frequent consultation with the Community Care professional advisors.Care managers focus on performance standards. They ensure that quality standards(performance standards) are met. Community Care created these standards inconjunction with providers, members, and other stakeholders with the goal of providingconsistent, high-quality care to all members. We accomplish this goal by offering writtenand specific quality standards by level of service and by using effective qualitymonitoring.To date, Community Care has created performance standards for:Acute Partial HospitalizationBehavioral Specialist ConsultationBHRS for Autism Spectrum DisordersCommunity Treatment Teams (CTT)Diversion and Acute Stabilization/RespiteDrug and Alcohol – Medically Monitored Short-Term Rehabilitation ProgramsDrug and Alcohol Partial HospitalizationFamily-Based Mental Health ServicesFamily-Focused Solution BasedIndividualized Residential Treatment/CRRInpatient ServicesMobile TherapyOutpatient ServicesPsychiatric RehabilitationCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 26

Psychiatric Rehabilitation ClubhousePsychologists and Psychiatrists Completing Best Practice EvaluationsResidential Treatment Facilities (RTF)School-Based OutpatientSchool-Based Partial Hospitalization ProgramSummer Therapeutic Activities ProgramTargeted Case Management: Intensive Case Management (ICM), ResourceCoordination (RC)TelepsychiatryCare Managers may refer to the “performance standards” as they are collaborating witha provider. Care managers ensure that:Clinical information given to the care manager meets the standards and guidelinesfor MNC review.All information is complete and up to date.Information is clear and specific.Performance standards for that specific level of care are met.Because care managers collaborate closely with providers during the utilizationmanagement process, they can often provide additional oversight, consulting, andmonitoring to those providers who may be having difficulty meeting networkbenchmarking standards.For information about approval standards refer to Guidelines for Obtaining Approval forIn-plan Services at the beginning of this guide. Authorization is based on administrativeand Medical Necessity Criteria. For information about Medical Necessity Criteria, referto Section IV.B or visit our website at:http://www.ccbh.com/providers/phealthchoices/medicalnecessityFor more information about Performance Standards, visit our website at:http://www.ccbh.com/providers/phealthchoices/performancestandardsCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 27

II. About Community Care HealthChoices MembersCommunity Care’s HealthChoices members are individuals for whom Community Carehas been contracted to manage behavioral health—mental health or drug and alcohol—services (See Guidelines for Obtaining Approval for In-plan Services at the beginning ofthis Provider Manual).When Community Care receives enrollment information, our Customer ServicesDepartment verifies eligibility. Customer services representatives serve as the point ofcontact for members until they use a service other than routine outpatient behavioralhealth services, at which time a care manager is assigned.Community Care offers a toll-free Members’ Line that is staffed 24 hours a day, sevendays a week to address all member inquiries and concerns, including services covered,selecting a behavioral health provider, out-of-area care, and complaints. In accordancewith quality standards, the member is able to speak to a customer servicesrepresentative at any time of the day or night. Every members is encouraged to read theCommunity Care Member Handbook.Information concerning members and services that providers need to know is describedin the following Sections:A. Member Rights and ResponsibilitiesB. Member Help in Selecting ProvidersC. Member SatisfactionD. Member Behavioral Health Preventive Health ProgramsE. Member Complaint and Appeal ProceduresF. Member GrievancesProviders are asked to urge members who have questions about their behavioral healthcare to call the toll-free Community Care Members' Lines (Customer service phonenumbers are listed by county in the Contact Information section of this manual).II.A. Member Rights and ResponsibilitiesAll members of Community Care have certain rights and responsibilities. Every staffperson and provider has the obligation and responsibility to know these rights andresponsibilities and to support them in daily operations.Member responsibilities are intended to serve as guidelines to help the member,provider and others work cooperatively and effectively for the member's benefit.Member responsibilities are not a threshold (required) standard of behavior and mustCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 28

always be considered in light of the nature of the member's illness and his or herparticular circumstances.II.A.1 Member RightsConfidentiality:Community Care will not disclose information about a member’s care withoutpermission, except when:It is required for the monitoring activities of Community Care, the counties, and/orthe state.Required by law.Members have the right to ask for a copy of the following information:The names, addresses, and phone numbers of providers who speak otherlanguages.The names, addresses, and phone numbers of providers who are not accepting newpatients.Any reasons why they could not choose a provider of service. For example,Community Care will not provide referral information for treatment services that arenot generally recognized by doctors.Their member rights and responsibilities.Information about grievances and fair hearing procedures.The benefits available to them, in detail.How to learn about additional benefits from the state of Pennsylvania.The steps that they (or a provider) need to take to receive services.The steps that must be taken to use a provider of service who is not in the network.Information about the emergency benefits available to them including “what is anemergency”; the steps for getting emergency services (including calling 911); thenames, addresses, and phone numbers of providers of emergency services,emergency services not requiring approval; any hospital being used when there isan emergency; and how emergency transportation is provided.Members also have the right to:Receive information about Community Care, our services, our providers, and themember rights and responsibilities.Receive proper treatment regardless of race, color, religion, lifestyle, sexualorientation, disabilities, national origin, age, gender, or income.Be treated in a considerate and respectful manner with recognition of their dignity.Receive services where their privacy is protected.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 29

An open discussion of appropriate or medically necessary treatment options for theirconditions, regardless of cost or benefit coverage.Choose any provider from the Community Care provider list. Members are free tochange providers if they are unhappy.Have their information kept private and confidential.Know the name and qualifications of any provider caring for them.Voice complaints or grievances about Community Care or the care they receive andto see how Community Care responds to member complaints and grievances.Members have the right to a fair process that is easy to follow.Make recommendations about Community Care’s member rights andresponsibilities.Receive a copy of the information that Community Care uses when deciding whatcare the member should receive.Know about the services they are receiving, why they are receiving them, and whatto expect.Know everything they need to know to make decisions about their care.Work with providers or interpreters who understand them and their community.Get information about Community Care that is clear and easy to understand.Tell Community Care is they are unhappy about any decision made by CommunityCare or one of our providers. Members have the right to a fair process that is easy tofollow.Know about the qualifications of Community Care providers and staff.Receive information about options for their treatment. They have the right to receivethis information in a way that is easy to understand.Play a part in the decisions about their care. They also have the right to refusetreatment.Not be restrained (tied down or locked in) or left alone – as a way for someonegiving them treatment to bully or punish them, or as a way for that person to take abreak.Ask for a copy of their medical record. They have the right to correct informationinside their record.Know their rights and to not be treated differently because they do.A second opinion.Ask and learn more about “Advance Directives.”II.A.2 Member ResponsibilitiesIt is important for members to:Give Community Care and their provider the information needed to provide care forthem.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 30

Tell their provider everything they know about their physical and mental health. Also,they need to tell their provider what medicines they are taking, including over-thecounter(store bought) medicine(s).Tell their family doctor or primary care physician (PCP) about any counselingtreatment.Carry their ACCESS, physical health plan (or ACCESS Plus), and Community CareID cards with them.Go to a Community Care participating hospital in an emergency, if possible.Members need to call Community Care within 24 hours if they have been seen foran emergency at a hospital that is not in the Community Care provider network.Keep their appointments. Members need to call ahead to cancel if they must.Understand their health problems and work together with their provider and agreeupontheir treatment plan.Follow the treatment plan they agreed upon with their provider.Tell their provider if they want to stop or change treatment.Tell Community Care and their provider about any other insurance they have.Tell Community Care and their provider right away if their Medicaid status changes.Tell Community Care and their provider right away if they move.II.B. Member Help in Selecting ProvidersCommunity Care customer services representatives assist members who ask for help inidentifying a provider who will meet their needs. To obtain a selection of providers in therequested specialty, location, etc., the representative consults Community Care'sPsychConsult MCO ® database, which contains the most current information providershave supplied to Community Care. A representative may disclose the followinginformation about prospective providers to help the member choose:SpecialtyOffice location, telephone number, and office hoursGenderProfessional credentialsLanguages spoken by provider/provider staff if this information was disclosed on thecredentialing/recredentialing or assessment/reassessment application formA representative may not disclose providers' malpractice limits and/or history, NationalPractitioner Data Base information, or Drug Enforcement Agency (DEA) number. Arepresentative will not refer members to a provider who is not currently accepting newclients or indicate a preference of one provider over another. If the member requiresadditional assistance in selecting a provider, the call will be referred to a care manager.Members may ask to change their provider at any time.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 31

II.C. Member SatisfactionMember satisfaction is the highest priority for Community Care. Dedicated to improvingthe satisfaction of members, Community Care contracts an outside survey company toconduct an annual Member Satisfaction Survey for members and family members ofchildren and adolescents. The survey tool used is the Experience of Care and HealthOutcomes (ECHO) Survey. Information from this survey is important to qualitymanagement programs such as the Comprehensive Provider Evaluation Process (SeeSection III.I.).Community Care has modified the ECHO Survey tool to include additional questionsthat help determine if members and family members of children and adolescents areknowledgeable about and satisfied with additional Community Care core functions suchas satisfaction with BHRS authorizations.In addition, because the ECHO survey is widely used, results on the ECHO survey canbe used to benchmark the satisfaction results of surveys against national averages. Allresults are analyzed, reviewed, and presented to Community Care’s Quality and CareManagement Committee (QCMC). The committee identifies areas for improvement andinterventions are developed to increase satisfaction in those targeted areas.Community Care additionally uses data about member complaints to assess membersatisfaction with care and services. The QCMC reviews and analyzes complaint dataroutinely and, as appropriate:Identifies opportunities for improvement.Determines interventions to improve performance.Oversees implementation of interventions to improve performance.Establishes re-measurement schedules to measure the effectiveness ofperformance improvement interventions.The categories used to analyze member complaints include access to services (SeeSection IV.D.), attitude and service, quality of care (See Complaint Section II.E), culturalcompetence (See Section III.H), and billing (Section V).II.D. Member Behavioral Health Preventive Health ProgramsCommunity Care offers preventive health programs for members. Each preventivehealth program is designed to help members learn new ways to make their treatmentmore helpful. The programs are free to members and are designed to complement theinformation about diagnosis and treatment that members receive from their providers.Programs that address depression and attention deficit/hyperactivity disorder (ADHD)are offered. These programs are evaluated based on surveys of participating membersCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 32

and calls received on the programs’ toll-free telephone information line (1-866-639-2943). Members may opt out of any Preventive Health program, if they wish, by calling1-866-639-2943.Community Care's toll-free Preventive Health Program information line (1-866-639-2943) provides member information about depression and attention deficit hyperactivitydisorder. Providers are encouraged to share this information with members.II.D.1 Provider Information and Preventive Behavioral Health Program:DepressionII.D.1a ImplementationDepression is the most common diagnosis among adults between the ages of 18 and64 among Community Care’s membership. Antidepressant medications are nowfrequently prescribed alone, or in combination, as a first-line treatment for depression.Many individuals also participate in psychotherapy for depression. For both of thesetreatment approaches, compliance issues and member behavior in relation to thetreatment can pose major barriers in an otherwise highly effective treatment regimen.Community Care views the role of educating members about the treatment process,helping them understand their experience of treatment, and encouraging them toassume an active role in their treatment as factors critical to ensuring effective treatmentand preventing relapse. This program helps members understand the course oftreatment, how treatment works, and what kind of effects they might anticipate. Theprogram emphasizes communication with providers and educates participants aboutself-care during treatment and recovery. Helping members understand their role in thetreatment process can have a positive impact on the treatment of depression, aiding intheir return to baseline levels of functioning at work and at home.II.D.1b GoalsThe goals of Community Care’s Preventive Health Program for depression are:To educate members about depression.To help members identify symptoms to track improvement over the course oftreatment.To educate members about how antidepressants work.To educate members about psychotherapy.To help members understand what they can expect from treatment.To help members anticipate the effects of antidepressant medications and the sideeffects they may encounter.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 33

To help members understand the importance of participation in and compliance withpsychotherapy.To encourage members to communicate with their providers about their treatment.To instruct members in ways they can improve their recovery from depression.II.D.1c Criteria for Member InclusionThis program is designed for members ages 18 and over who have been diagnosedwith a depressive disorder (DSM-IV codes: 296.20-296.36, 300.4 and 311) as a primaryor secondary Axis I diagnosis and who have been prescribed antidepressantmedications and/or are being treated with psychotherapy. This program is not intendedfor individuals who have been diagnosed with bipolar disorders and other mooddisorders not indicated by the codes listed above.II.D.1d InterventionsThis program consists of three educational newsletters, which are mailed to memberswho recently received authorization for medication management and/or psychotherapyand for whom authorization data indicate a diagnosis of a depressive disorder. Copiesof all three newsletters are available on Community Care’s website athttp://www.ccbh.com/providers/memberhelp/preventivehealth.We encourage you to review them.The first newsletter focuses on basic information about depression and helps individualsto identify symptoms that they are experiencing. This information is designed to helpparticipants develop a vocabulary to discuss or describe their feelings and any changesin symptoms during their treatment. This module also introduces members to importantaspects of their care—types of psychotherapy treatment approaches, how theirmedication was chosen and basic information about side effects.The second newsletter emphasizes ways in which members can make the most of theirtreatment. This includes further information about medications including a discussion ofthe symptoms, which are most responsive to antidepressants, common side effects thatthey may experience, and how they can work with their provider to balance the positiveand negative effects of their medications. Similarly, members are provided informationabout how to optimize their psychotherapy treatment. In this regard, the newsletteraddresses several components of the psychotherapy process critical to effectivetreatment. Finally, self-care issues relevant to making changes outside of treatment,which can facilitate symptom remission, are introduced.The third newsletter educates members about the process of recovery from depression,treatment continuation and maintenance. It also elaborates on self-care issuesimportant in recovering and maintaining improvement after treatment.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 34

II.D.1e EvaluationIndividuals participating in the program are mailed (with a postage paid envelope) abrief survey assessing their perceptions of the usefulness of this program. Follow upphone calls are made to those members who choose to provide contact information.Over time, additional evaluation strategies may be added such as asking participatingmembers to complete a medication compliance inventory or tracking data on treatmentcontinuation or losses to follow-up using Community Care’s claims data.II.D.1f Availability to MembersAt least annually, Community Care informs our members about this preventivebehavioral health program. This information is communicated to members throughnewsletters or the Community Care website athttp://www.ccbh.com/healthchoices/preventiveprograms.Members are encouraged to take advantage of the program and are told how to obtainthe materials. Members who meet diagnostic eligibility criteria based on authorizationand treatment plan data automatically receive an introductory letter describing theprogram and information on how to opt out of the program if they desire.The educational modules described above are mailed out to participating members.Following the introductory letter, newsletters are mailed out at four-week intervals. Ifmembers choose not to participate in the program or wish to have the newsletters sentto a different address, they can call the toll-free preventive health program number (1-866-639-2943).II.D.1g What Providers Can DoCommunity Care’s prevention program is designed to increase the members’awareness of the important role they play in the effective treatment of their depression.Your support of this program is important to us. While Community Care contactsmembers automatically through the identification processes described above, you areencouraged to inform members about this program and call us with the name of anymember who meets the inclusion criteria.Participating members may seek additional information from you or have questionsregarding the issues discussed in the educational materials. We hope this will positivelyinfluence your treatment relationship and assist you in caring for our members.The Provider and Member materials are included on Community Care’s website at thelinks above. If you do not have access to the Internet please call toll-free 1-866-639-2943 and we will send the information to you. Please take the time to read thesematerials and give us your feedback. It is our hope that you find these materials avaluable addition to the care you provide.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 35

If you have questions or concerns, or would like to discuss the program, please contactus at 1-866-639-2943.II.D.2 Provider Information and Preventive Behavioral Health Program:Attention Deficit Hyperactivity Disorder – Your Child and YouCommunity Care offers a preventive health program for parents/guardians of childrenwho are being assessed for, or have been diagnosed with, Attention DeficitHyperactivity Disorder (ADHD). This program is designed to improve clinical outcomesfor both children and their parents/guardians by educating them about the disorder andhow to work more effectively with their children.This educational program complements the care that you provide. Together with yoursupport, Community Care can help parents/guardians recognize the effect of ADHD ontheir lives and the lives of their children. This program can help teach parents/guardiansto take active steps to foster communication, help modify problem behaviors in thehome and reduce the distress, which they and other family members may experience incaring for a child with ADHD.Information about the program follows along with a description of what you can do toassist us in this important preventive health initiative—which we believe will have apositive benefit for the children in your care.II.D.2a ImplementationAttention deficit and disruptive behavior disorders are among the top diagnoses forchildren (ages 0-12 years) whose behavioral health care is managed by CommunityCare. Care for children with ADHD extends beyond medication management andbehavioral therapy with the child. Important to helping children with ADHD is thedevelopment of a family environment in which the child can prosper and feel supported.In treating a child with ADHD, the role of the parents/guardians in helping their child iscritical. This program helps parents/guardians learn how they can shape their child'sbehaviors and how they can provide an emotionally supportive and productiveenvironment for their child with ADHD. Parenting a child with ADHD can be anexhausting and frustrating experience, often leaving parents/guardians feeling helplessand without support or understanding. Parents/guardians may be strained or unable tomeet the special demands which parenting a child with ADHD requires. Empoweringparents/guardians through education and training can be an effective way to help themlearn to cope. Teaching parents/guardians skills, which translate into parentingapproaches appropriate to the unique needs of children with ADHD, can help restore asense of capability and confidence for parents/guardians and can help their childbecome more focused and productive.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 36

II.D.2b GoalsThe goals of Community Care’s Preventive Health program for Attention DeficitHyperactivity Disorder (ADHD) are:To educate parents/guardians about ADHD.To help parents/guardians develop more effective ways of relating, rewarding, anddisciplining their children.To help parents/guardians cope with the emotional toll that can accompanyparenting a child with ADHD.II.D.2c Criteria for Member InclusionThis program is directed to parents/guardians of children age 12 and younger who havebeen diagnosed with Attention Deficit Hyperactivity Disorder (DSM-IV codes 314.00;314.01 and 314.9) as a primary or secondary Axis I diagnosis.II.D.2d InterventionsThis program consists of several educational modules, which are mailed toparents/guardians of children who have recently received authorization for evaluation ortreatment of ADHD. All three newsletters are available on Community Care’s website athttp://www.ccbh.com/providers/memberhelp/preventivehealth.The first module helps educate parents/guardians about ADHD and suggests ways inwhich they might begin to assess how ADHD affects their child's life. The first modulealso includes an ADHD medication fact sheet to complement information that they arealready receiving from their doctor.The second module educates parents/guardians about effective ways to think abouttheir child's experience. It teaches parents/guardians how to communicate with theirchild and how to use structure, reinforcements, and discipline in an optimal way. Finally,because parenting a child with ADHD can be difficult and stressful, the third and lastmodule addresses ways parents/guardians can take better care of themselves bysuggesting ways they can creatively cope with the stress they may experience.II.D.2e AvailabilityAt least annually, Community Care informs our members about this preventivebehavioral health program. This information is communicated to members throughnewsletters and Community Care website athttp://www.ccbh.com/healthchoices/preventiveprograms.Members are encouraged to take advantage of the program and are told how to obtainthe materials. Parents/guardians of children who meet diagnostic eligibility criteriaCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 37

ased on authorization and treatment plan data automatically receive an introductoryletter describing the program and information on how to opt out of the program if theydesire.The educational modules described above are mailed to participating parents/guardians. Following the introductory letter, newsletters are mailed approximately everyfour weeks. Parents/guardians are provided a toll-free number (1-866-639-2943) to callif they choose not to participate in the program or wish to have the newsletters sent to adifferent address.II.D.2f EvaluationAssessing the effect of this program is important for improving and further developingmaterials and services offered through Community Care. Parents/guardiansparticipating in the program are mailed a brief survey (with a postage paid envelope)assessing their perceptions of the usefulness of this program. Follow-up phone calls aremade to those parents/guardians who choose to provide contact information.II.D.2g What Providers Can DoCommunity Care’s prevention program is designed to increase parental/guardianknowledge of how to more effectively work and cope with the problems their child faces.Helping parents/guardians develop effective skills can have a more positive clinicaloutcome for the child whom you have evaluated or to whom you may be providingservices. Your support of this program is important to us. While Community Care willcontact parents/guardians automatically through the identification processes discussedabove, you are encouraged to inform parents/guardians of children with ADHD aboutthe program and, with their consent, call us at 1-866-639-2943 with the name of anymember who meets the inclusion criteria.Participating parents/guardians with questions may seek information from you regardingissues in the educational materials. We believe that the educational materials will helpparents/guardians understand the basics and encourage you to help them furtherdevelop or practice the skills necessary for parenting a child with ADHD.The provider and member materials are included on Community Care’s website, at thelinks above. If you do not have access to the Internet please call (toll free) 1-866-639-2943 and we will send the information to you. Please take the time to read thesematerials and give us your feedback.It is our hope that you find these materials a valuable addition to the care that youprovide. Should you have any questions or concerns, we would be pleased to addressthem. To discuss the program, please call 1-866-639-2943.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 38

II.D.3 Providers’ Role in the Preventive Health ProgramProviders play an important role in the success of the Preventive Health Program.Community Care asks providers to make the educational newsletters available in theiroffices and to tell suitable members about the programs. In addition, Community Careasks providers to answer member questions about the educational newsletters and toprovide additional information if requested. Providers are also welcome to contactCommunity Care with suggestions or to learn about future programs.II.E. Member Complaint and Appeal ProceduresCommunity Care’s policy for the resolution of complaints has been developed toestablish an objective review process to investigate and resolve all complaints in anappropriate and timely manner and to meet all county, state, and NCQA requirements.We ensure impartial review by designating reviewers who are not associated with theissue being considered and have not already reviewed the issue.InquiryAn inquiry is defined as any member’s request for administrative services orinformation, or expressing an opinion. Whenever specific corrective action is requestedby the member or determined to be necessary by Community Care, an inquiry isclassified as a complaint.ComplaintA complaint is defined as a dispute or objection by a member or their representative,which may include the member’s provider, with proof of the member’s writtenauthorization for the representative, to be involved and/or take action on the member’sbehalf, regarding a participating health care provider, or the coverage (includingcontract exclusions and non-covered benefits), operations, or management policies ofCommunity Care that has not been resolved by our organization and has been filed withCommunity Care, the Pennsylvania Department of Health, or the PennsylvaniaInsurance Department. The term does not include a grievance.Second Level ComplaintA statement of disagreement, either written or oral, with the resolution of a complaint,which is perceived to be unsatisfactory by the member, which is subject to a secondlevel review within a 30-day timeframe.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 39

First Level Complaint ProceduresMembers, or their designated representatives, may use any verbal or written means tolodge a complaint. They can call using one of Community Care’s toll-free numbers orsend their complaint in writing to their local Community Care office or to the corporateoffice:Community Care Behavioral Health Organization112 Washington PlaceOne Chatham Center, Suite 700Pittsburgh, PA 15219The Customer Service toll-free numbers, staffed 24 hours a day/seven days a weekwith staff trained to handle complaints, are listed on the HealthChoices Key ContactPage of this manual. The toll-free corporate clinical fax number is 1-888-251-0087.Community Care will offer impartial assistance at no cost to members who choose toexercise this right.Members may also seek assistance at any time during this process from multiplesources to include a community support person/advocate/family member.Personnel receiving and processing complaints will abide strictly by the CommunityCare Confidentiality policy. No Community Care provider or staff member may in anyway retaliate against a member who registers a complaint. If the complaint involvesa Community Care staff member, that individual may not participate in decisionsregarding resolution of the complaint.Immediately upon knowledge of a complaint, a Community Care staff member willdocument and log the complaint in PsychConsult MCO ® to include the followinginformation: (a) member’s name and ID number; (b) name of complainant (if otherthan member); (c) nature of the complaint and summary of the facts; (d) date andtime complaint received; (e) name of the staff member receiving the complaint; and(f) what the complainant requests as a resolution.A staff member will attempt to immediately resolve the problem by telephone within24 hours or one business day.Community Care will attempt to resolve complaints at the lowest level possible,ideally through the customer service representative.If resolution cannot be reached within 24 hours, the staff member will log thecomplaint in PsychConsult MCO ® and a complaint and grievance coordinator willcontact the provider or other party to investigate the complaint. The member ormember representative will receive written acknowledgement that a complaint hasbeen filed within five business days of Community Care’s receipt of the complaint.If the complaint is against a provider, Community Care will send that provider a copyof the complaint acknowledgment letter, outlining the member’s concern(s).The provider should then respond in writing to Community Care, addressing eachconcern in a simple and straightforward manner.Community Care will then review all information received, make a decision about thecomplaint, and propose a resolution to the member or their representative.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 40

Community Care has a total of 30 calendar days, from the date of receipt, topropose a resolution to the complaint.The staff member will notify the complainant of resolution in writing within fivebusiness days of the resolution. The letter informing the member of the resolutionwill include: (a) the understanding of the complaint; (b) steps taken to resolve thecomplaint; (c) basis for decision; (d) the decision itself; (e) procedures for filing aSecond Level Complaint, including assistance available in filing a complaint at thenext level.The Complaints and Grievances Department will maintain a database of allcomplaints and resolutions.Second Level Complaint ProceduresIf a member is not satisfied with the proposed resolution of a complaint, the memberhas 45 calendar days, from the receipt of the letter proposing the resolution, to utilizethe Second Level Complaint procedure.Community Care will offer impartial assistance at no cost to members who choose toexercise this right.The member or member representative may notify Community Care in writing or callcustomer services utilizing the toll-free hotline to verbally request assistance in filinga Second Level Complaint. Customer services will log the complaint in PsychConsultMCO ® and a complaint and grievance coordinator will coordinate and schedule thesecond level meeting.All requests for a Second Level Complaint will be logged, identifying: (a) themember; (b) complaint date; (c) nature of the complaint; and (d) the requestedSecond Level Complaint resolution.The complaint and grievance coordinator will acknowledge in writing to the memberor member representative that a request for Second Level Complaint has beenreceived within five business days of receipt of the complaint.If the complaint is against a provider, Community Care will send that provider a copyof the complaint acknowledgment letter, outlining the member’s concern(s).The Second Level Complaint will be reviewed by a Second Level Complaint ReviewCommittee appointed by Community Care, or in some instances, a Community Careoversight entity. This committee will consist of the following membership: one-thirdwill be members enrolled in Community Care and will include an adult/adolescentmember, a person in recovery, or the parent/guardian of children and adolescentmembers, depending upon the nature of the complaint, one-third will be committeemembers and employees of Community Care (or in some instances, a CommunityCare oversight entity employee) who were not directly involved in the issue that isbeing resolved at the second level, and one-third will be members not employed byCommunity Care. A representative of the county or oversight entity may participatein the Second Level Complaint review. The appropriate Community Carerepresentative(s) will gather information concerning the complaint and may contactCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 41

the member or provider for more information to assist in the disposition of thecomplaint. Upon receipt of a request for a Second Level Complaint review, Community Carewill provide the member with written notification regarding the Second LevelComplaint Committee Review procedures and hearing. The member will be notifiedof established protocols for the hearing process, investigation of the complaint, andthe role of the Second Level Complaint Review Committee. These protocols areconsistent with the requirements of the Department of Public Welfare and theDepartment of Health. A hearing of the Second Level Complaint Review Committee will be held within 30days of the receipt of the request for the hearing and will be conducted at a time andplace convenient to the member. The member will be notified in writing of thescheduled hearing at least 15 days in advance and will be invited to appear. Themember may elect not to attend the Second Level Complaint Review Committeehearing at his/her discretion; the hearing will be conducted by the same protocols asif the member were present. The member always has the right to attend and to present the case and has a rightto be assisted/represented by persons of his/her choice. The member may submitwritten material and has a right to question Community Care staff or the providerabout the complaint. The committee may not discuss the case to be reviewed prior to the second levelreview meeting. The committee shall base its decision solely upon the materials andtestimony presented at the review. Formal rules of evidence are inappropriate as this proceeding is envisioned as aninformal attempt to amicably resolve differences. The Second Level Complaint Review Committee is expected to conduct an informaland impartial proceeding using as the basis for their deliberation the written decisionof the First Level Complaint review. Committee members will be clearly identified asto staff and subscriber members. The Committee is to consider this dispute basedsolely on the material and presentations during the hearing. If an attorneyrepresenting the Second Level Complaint Review Committee is present, the attorneywill represent the interest of the impartial committee and not the staff memberinvolved in the dispute. Staff previously involved in the complaint may present andsummarize the decision for the Committee. The Committee will be permitted toquestion Community Care staff and the provider. An audio recording of the Second Level Complaint Review Committee hearing willbe made as required by the Department of Public Welfare and Department ofHealth. Electronic records will be kept for at least three years by the Complaint andGrievance Department. Access to this information will be limited to the director ofcomplaints and grievances, complaint and grievance coordinators, quality managers,Chief Clinical Officer, and Chief Medical Officer, or their designee, and will beavailable for appeal review by the Department of Health or Insurance Department. The Second Level Complaint Review Committee will issue a written decision withinfive business days of the hearing. The notice will contain: (a) an understanding ofthe complaint and pertinent facts; (b) the decision itself, the basis of the decision,and rationale; (c) an explanation of the member’s right to request review by theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 42

Department of Health and provide instructions for the member to request such areview. Community Care will assist the member in preparing the necessarydocumentation for the external review if requested to do so by the member.General Complaint Procedure ProvisionsA description of Community Care’s complaint procedure is communicated to membersthrough the Member Handbook, member newsletter (annual notification), routinecontact with Community Care representatives by telephone or mail, and is posted inprovider offices within members’ view.Community Care will comply with all requirements of the Department of Health andDepartment of Public Welfare to provide monthly, quarterly and annual reports on allcomplaints received. All such reports will contain member codes rather than identifyinginformation to ensure that member confidentiality is maintained of the complaintsystems/operational standards for fundamental fairness. The county or oversight entityhas access to all documentation regarding complaints and actions taken in response tocomplaints. If the county or its governance and oversight entity is in disagreement withany decision made by the Second Level Complaint Review Committee, the party withthe disagreement will prepare a summary document addressing his or herdisagreement. Copies of this document will for forwarded to Community Care and to theDepartment of Health.Community Care will accept complaints from individuals with disabilities which are inalternative formats including:TTY for telephone inquiries and complaints from members who are hearingimpaired.Braille, tape, computer disk, and other commonly accepted alternative forms ofcommunication.Community Care will provide members with disabilities assistance in presenting theircase at complaint reviews at no cost to the member. This includes:Providing qualified sign language interpreters for members who are severely hearingimpaired.Providing information submitted on behalf of Community Care at the complaintreview in an alternative format accessible to the member filing the complaint. Thealternative format version will be supplied to the member at or before the review, sothe member can discuss and/or refute the content during the review.Providing personal assistance to members with other physical limitations in copyingand presenting documents and other evidence.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 43

II.F. Member GrievancesCommunity Care is accountable to its members for the effective utilization of resourcesin the provision of health care and the quality of care and services provided by ourparticipating providers. Community Care reviews requests from providers for behavioralhealth services to ensure that only medically necessary services are approved. TheCommunity Care review may result in the denial of a requested service for a lack ofdocumented medical necessity or a recommendation for alternative services to achievethe proposed treatment outcomes.From time to time, a member, a family member or parent/guardian of a member will notbe in agreement with determinations of medical necessity made in fulfillment of thisaccountability. At such times, the member, their provider (with written permission of themember), or the parent/guardian (if the member is a minor or in foster care), have theright to file a grievance in writing to Community Care. Grievances are available toaddress disagreements in adverse determination decisions. All Community Carepersonnel involved in this grievance procedure shall comply with all policies regardingconfidentiality and conflict of interest to ensure that the confidentiality of memberinformation is maintained.If services which have previously been authorized by Community Care are beingdiscontinued or reduced by our organization, we acknowledge an obligation to continueauthorization of care until all formal grievances have been completed, consistent withthe requirement of the Department of Public Welfare (if grievances are requested withinrequired timeframes).GrievanceA grievance is a request by a member or their authorized representative, or by a healthcare provider with the written consent of the member or guardian, to have CommunityCare or a Certified Review Entity (CRE) reconsider a decision solely concerning themedical necessity and appropriateness of a health care service. If Community Care isunable to resolve the matter, a grievance may be filed regarding the decision that doesany of the following:Disapproves full or partial payment for a requested health service.Approves the provision of a requested health care service for a lesser scope orduration than requested.Disapproves payment of the provision of a requested health care service butapproves payment for the provision of an alternative health care service. The termdoes not include a complaint.Information regarding Community Care’s policies and procedures regarding grievancesis made available to the provider network through their inclusion in the Provider Manual.Provider training includes a review of these policies.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 44

An explanation of the grievance process is included in the Member Handbook. A copyof the same information is provided to the Independent Enrollment Assistance Project(IEAP). The IEAP receives new information regarding the grievance procedure as theseprocedures are updated. Community Care will provide training on the grievanceprocedures to the IEAP as requested.Staff education regarding grievance policies and procedures is included in the StaffTraining Plan. Adequate staffing is available to handle the processing of grievances.Denials, Grievances, and Continuation of ServicesWhen a request to continue a non-urgent service that a member receives ispresented to Community Care, Community Care must make its medical necessitydecision within two business days of receipt of sufficient information to reasonablybe able to make that decision.If the decision is to deny (total denial, partial denial of duration or volume,substitution of another service) the service, Community Care must provide themember advance notice of the effective date of that decision. Under normalcircumstances, the member must have 10 calendar days advance notice. (Forexample, if the decision is to reduce a request to continue a service and the decisionis made and the member and provider are informed via letter on November 1, theeffective date of the decision would need to be no sooner than November 11).If the service duration is so short that a 10 day advance notice is not possible, e.g.,Acute Inpatient Mental Health Treatment, the member must receive the notice inadvance of the effective date of the denial. In addition, the notice must provide themember time (at least one calendar day) to file a grievance or request a Departmentof Public Welfare (DPW) Fair Hearing before the effective date of the denial.If the member files a First Level Grievance before the effective date of the servicedenial, services must continue until the outcome of that grievance is conveyed andthe member is provided an opportunity to request further review or until theprescription runs out, whichever is the shorter time period. If the member requests aDPW Fair Hearing before the effective date of the service denial, services mustcontinue until the outcome of the DPW Fair Hearing is conveyed to the member oruntil the prescription runs out, whichever is the shorter time period.If the member files a Second Level Grievance before the effective date of the FirstLevel Grievance decision, services must continue until the outcome of the SecondLevel Grievance is conveyed and the member is provided an opportunity to requestan External Grievance or a DPW Fair Hearing or until the prescription runs out,whichever is the shorter time period. If the member requests a DPW Fair Hearingbefore the effective date of the First Level Grievance decision, services mustcontinue until the outcome of the DPW Fair Hearing is conveyed to the member oruntil the prescription runs out, whichever is the shorter time period.If the member files an External Grievance before the effective date of the SecondLevel Grievance decision, services must continue until the outcome of that grievanceis conveyed and the member is provided an opportunity to request further review orCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 45

until the prescription runs out whichever is the shorter time period. If the memberrequests a DPW Fair Hearing before the effective date of the Second LevelGrievance decision, services must continue until the outcome of the DPW FairHearing is conveyed to the member or until the prescription runs out, whichever isthe shorter time period.Community Care may, at its discretion, assume that a member who files a First LevelGrievance which results in a continued denial will automatically file a Second LevelGrievance and automatically continue the service until the end of that time period.Community Care, at its discretion, can further assume that a member who receives adenial the Second Level Grievance will automatically request an External Grievanceand automatically continue services during that process.Standard GrievanceThe member or their designated representative may initiate a standard grievance inwriting or by phone, in which case, Community Care will acknowledge the receipt of thegrievance in writing. The member’s provider, with the member’s written permission, mayfile a grievance. This may be done via phone, or may be faxed or mailed to CommunityCare. If the grievance is filed via phone, the member or provider must follow up with awritten, signed grievance request.In order for the provider to represent the member in the filing of a grievance, theprovider must obtain the written consent of the member or the member’s guardian. Aprovider may obtain the member’s written permission at the time of treatment. Aprovider may NOT require a member to sign a document authorizing the provider to filea grievance as a condition of treatment.The written consent must include all of the following:The name and address of the member, the member’s date of birth and identificationnumber. If the member is a minor, or is legally incompetent, the name, address, andrelationship to the member of the person who signed the consent.The name, address and plan identification number of the provider to whom themember is providing consent.The name and address of the plan to which the grievance will be submitted(Community Care).An explanation of the specific service for which coverage was provided or denied tothe enrollee to which the consent will apply.The following statement: “The member or the member’s representative may notsubmit a grievance concerning the services listed in this consent form unless themember or the member’s representative rescinds consent in writing. The member ormember’s representative has the right to rescind consent at any time during thegrievance process.”Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 46

Upon request, the member will be assisted, at no cost, by Community Care staff incompleting forms and other procedural steps related to the grievance. The member (ortheir designated representative) is allowed before, or during the grievance process, toexamine their case file, including medical records, upon request to Community Care.Community Care will accept grievances from individuals with disabilities which are inalternative formats including:TTY for telephone inquiries and grievances from members who are hearingimpaired.Braille, tape, computer disk, and other commonly accepted alternative forms ofcommunication.Community Care will provide members with disabilities assistance in presenting theircase at grievance reviews at no cost to the member. This includes:Providing qualified sign language interpreters for members who are severely hearingimpaired.Providing information submitted on behalf of Community Care at the grievancereview in an alternative format accessible to the member filing the grievance. Thealternative format version will be supplied to the member at or before the review, sothe member can discuss and/or refute the content during the review.Providing personal assistance to members with other physical limitations in copyingand presenting documents and other evidence.Once initiated, the subsequent steps of a standard grievance are:A First Level Grievance acknowledgement letter will be sent to the member (or totheir guardian or representative if applicable), with a copy to their treating prescriberand provider within five business days of Community Care’s receipt of the First LevelGrievance.The practitioner, member and/or family member/guardian will be made aware of thedocumentation required for resolution of the grievance. Documentation may includesending copies of part or all of the medical record and/or a written statement fromthe practitioner.The member will be afforded a reasonable opportunity to present evidence, andallegations of fact or law, in person as well as in writing. Community Care will beflexible when scheduling the review to facilitate the member’s attendance. If themember cannot appear in person at the review, an opportunity to communicate withthe First Level Grievance review committee by telephone or videoconference will beprovided.A Community Care professional advisor (a psychiatrist or licensed, doctoralprepared psychologist), who is a health care professional with clinical expertise intreating the member’s condition or disease, and was not involved in the initial denialdetermination, will review the documentation provided.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 47

Determinations will be made within 30 calendar days of the request for a First LevelGrievance. The final determination will be in writing and sent to the member withinfive business days of the decision and will include the clinical reasons for thegrievance determination.Community Care may extend the timeframe for determination by up to 14 calendardays if the member requests the extension, or if Community Care shows that there isneed for additional information, and states how the extension is in the member’sbest interest.The basis for the determination will be provided to the attending practitioner and themember. The member will be informed of their right (and how) to file a Second LevelGrievance with Community Care, or a DPW Fair Hearing.First Level Grievance: Urgent ServiceIf the service prescribed is in response to an urgent situation, Community Care willnotify the member and provider by phone, follow up in writing, and apprise them ofthe full or partial denial of authorization for the service or the approval of analternative to the prescribed service and the member’s right to appeal that decision.If the member, either verbally or in writing, or the provider, with written permission ofthe member, indicates that the member wishes to grieve the decision, it will bereviewed by a professional advisor (PA). The reviewer cannot be the same PA whomade the original denial decision. This decision will be rendered within 24 hours ofreceipt of the grievance.If the First Level Grievance results in a determination that Community Care willauthorize provision of the service as originally prescribed, the member and theprovider must be notified by phone, followed-up in writing within 48 hours.If the First Level Grievance results in a determination that Community Carecontinues to deny authorization for provision of the service or continues to approvean alternative to the prescribed service, the member and provider will be notified byphone, followed-up in writing, also within 48 hours.The notice will inform the member of the member’s right to a Second LevelGrievance and provide information about how to request a Second Level Grievance.Community Care must assist the member, if necessary, to make a written request.The notice will also inform the member of the member’s right to request a DPW FairHearing and how to file for a Fair Hearing.First Level Grievance: Non-urgentIf the service prescribed is not in response to an urgent situation, Community Carewill notify the member and provider, in writing, of the full/partial denial ofauthorization for the service or the approval of an alternative to the prescribedservice, the effective date of the decisions, and the member’s right to grieve thatdecision. A copy of the written denial will be provided to the parent/guardian of achild or adolescent or to the county’s Children and Youth Services (subject to anyCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 48

Notices must be in alternate formats that allow access for all individuals. The right toa DPW Fair Hearing may be exercised at the same time that the member uses theCommunity Care grievance process or in lieu of Community Care’s grievanceprocess. A copy of the notice must also be sent to the provider who requested theservice being denied.At all phases of Community Care’s grievance process, the member has the right torequest a DPW Fair Hearing from the OMHSAS Division of Grievances and Appeals.A member can appeal the initial determination and/or the results of the First orSecond Level of Grievance decision by Community Care.A member may request a Fair Hearing within 30 days of the date on the initial writtennotice of decision and within 30 days from the date on a complaint or grievancenotice of decision at any level, of any of the following:• The denial, in whole or in part, of payment for a requested service if based onlack of medical necessity.• The denial of a requested service on the basis that the service is not a coveredbenefit.• The denial or issuance of a limited authorization of a requested service, includingthe type or level of service.• The reduction, suspension, or termination or a previously authorized service.• The denial of a requested service but approval of an alternative service.• The failure to provide services in a timely manner, as defined by DPW.• The failure of Community Care to decide a complaint or grievance within thetimeframes specified by DPW.• The retrospective denial of payment because the service(s) was provided by anout of network non-Pennsylvania Medical Assistance participating providerwithout authorization.The request for a fair hearing must include a copy of the written notice of decisionthat is the subject of the request. Requests should be sent to:Department of Public WelfareOffice of Mental Health and Substance Abuse ServicesDivision of Grievance and AppealsBeechmont Building #32P.O. Box 2675Harrisburg, PA 17105-2675A member who files a request for a Fair Hearing to dispute a decision to discontinue,reduce, or change a service that the member has been receiving must continue toreceive the disputed service at the previously authorized level pending resolution ofthe Fair Hearing, if the request for a Fair Hearing is hand delivered or post-markedwithin 10 days of the date of the written notice of decision (within 1 calendar forurgent care decisions).Upon the receipt of the request for a Fair Hearing, the Department’s Bureau ofHearings and Appeals or a designee will schedule a hearing. The member andCommunity Care will receive notification of the hearing date by letter at least 10 daysin advance, or a shorter time if requested by the member. The letter will outline theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 54

type of hearing, the location of the hearing (if applicable), and the date and time ofthe hearing.Community Care is a party to the hearing and must be present. Community Care,which may be represented by an attorney, will be prepared to explain and defend theissue on appeal. The DPW’s decision is based solely on the evidence presented atthe hearing.Community Care will provide members, at no cost, with records, reports, anddocuments, relevant to the subject of the Fair Hearing.The Bureau of Hearings and Appeals has up to 90 days from the receipt of a requestfor a Fair Hearing to process final administrative action. If the Bureau of Hearingsand Appeals has not taken final administrative action within 90 days of the receipt ofthe request, Community Care shall follow the requirements at 55 Pa. Code 275.4regarding the provision of interim assistance upon the request for such by themember. When the member is responsible for delaying the hearing process the timelimit for final administrative action will be extended by the length of the delayattributed to the member (55 Pa. Code 275.4).The Bureau of Hearings and Appeals’ adjudication is binding on Community Careunless reversed by the Secretary of Public Welfare. Either party may requestreconsideration from the Secretary within 15 days from the date of the adjudication.Only the member may appeal to Commonwealth Court within 30 days from the dateof adjudication (or from the Secretary’s final order, if reconsideration was granted).The decisions of the Secretary and the Court are binding on Community Care.Expedited Fair Hearing ProcessA request for an Expedited Fair Hearing may be filed with DPW either in writing ororally.A member does not have to exhaust the complaint or grievance process prior tofiling a request for an Expedited Fair Hearing.An Expedited Fair Hearing will be conducted if a member or a member’srepresentative provides the DPW with written certification from the member’sprovider that the member’s life, health, or ability to attain, maintain, or regainmaximum function would be placed in jeopardy by following the regular Fair Hearingprocess. This certification is necessary even when the member’s request for theExpedited Fair Hearing is made orally. The certification must include the provider’ssignature.A member who files a request for an Expedited Fair Hearing to dispute a decision todiscontinue, reduce, or change a service that the member has been receiving mustcontinue to receive the disputed service at the previously authorized level pendingresolution of the Fair Hearing, if the request for an Expedited Fair Hearing is handdeliveredor post-marked within 10 days of the date from the written notice ofdecision (within 1 calendar for urgent care decisions).Upon the receipt of the request for an Expedited Fair Hearing, the DPW’s Bureau ofHearings and Appeals or a designee will schedule a hearing.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 55

Community Care is a party to the hearing and must participate in the hearing.Community Care, which may be represented by an attorney, must be prepared toexplain and defend the issue on appeal. The failure of Community Care toparticipate in the hearing will not be reason to postpone the hearing.Community Care must provide members, at no cost, with records, reports, anddocuments, relevant to the subject of the Fair Hearing.The Bureau of Hearings and Appeals has three business days from the receipt ofthe member’s oral or written request for an expedited review to process finaladministrative action. The Bureau of Hearings and Appeals’ adjudication is bindingon Community Care.III. About Being a Community Care HealthChoices ProviderCommunity Care's goals in developing and supporting a network of HealthChoicesproviders are to:Have a comprehensive range of providers to deliver all behavioral health servicescovered under HealthChoices regardless of participation in Federal Health CarePrograms under Sections 1128 or 1128A of the Social Security Act.Offer an adequate number of practitioners and facilities appropriately dispersedthroughout Community Care’s service area to allow for easy and convenient accessby members.Offer a sufficient number of specialist and ancillary providers to permit ample choicefor referrals regardless of cost.Community Care’s goals are also to include providers who:Serve high-risk populations.Have demonstrated a commitment to public sector consumers.Are committed to implementing treatment services that are consistent with theprinciples of the Community Support Program (CSP), Bureau of Drug and AlcoholPrograms (BDAP), and the Child and Adolescent Service System Programs(CASSP).Have worked to involve consumers and families actively in the design andimplementation of treatment programs.Have understood the relevance of psychosocial assessments in the design andimplementation of treatment.Represent both general and specific treatment skills.Will broaden access to assessment and treatment services, provided in a respectfuland competent manner.All providers of behavioral health services that are identified to participate in any ofCommunity Care’s networks are required to participate in a network managementCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 56

screening process prior to being offered an application. Community Care then reviewsthis information with its county partners prior to make a network inclusion decision.Community Care prospectively identifies member needs based on knowledge of priorservices used, psychosocial factors, member and family suggestions and providerexperience. The geographic distribution and demographic characteristics of membersare analyzed as well as the provider’s ability to meet the assessed and expectedmember needs.In the event that a provider is denied network inclusion, the provider is notified in writingby the Network Relations Department of the decision. A clear rationale for the decisionand an explanation of the right to appeal is included.Community Care contracts with the following types of providers of behavioral healthservices:Practitioners in individual or group practice (physicians, psychiatrists,addictionologists), doctoral or masters-level licensed clinical psychologists, doctoralor masters-level clinical psychiatric nurse specialists, doctoral or masters-levellicensed social workers and other masters or doctoral-level licensed behavioralhealth clinicians).Facilities (facilities and organizations).Providers (denotes information that applies to both practitioners and facilities).The Community Care credentialing program is committed to:Careful selection, credentialing, and recredentialing of practitioners to ensure thatmembers receive quality care and services from qualified professionals.Thorough assessment of facilities to ensure that members receive quality care andservices in a full continuum of settings.Maintaining the confidentiality of provider related information in the provider files aswell as the Credentialing Committee:• All Credentialing Department staff and reviewers sign employee confidentialitystatements.• All Credentialing Committee members sign confidentiality statements.• Each Credentialing Committee meeting is opened with a statement regarding theconfidentiality of printed material and discussions related to providers.• Provider specific materials prepared for the Credentialing Committee areproprietary and remain at Community Care following the CredentialingCommittee meeting.• Provider files are maintained in locked file cabinets at Community Care.Make available to providers, upon written request, the ability to view any materials,except recommendations, National Practitioner Data Bank (NPDB) responses, andother peer-review protected documents, submitted in relation to their applications.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 57

The following sections provide information about providing quality care to CommunityCare’s members, including how to become a contracted provider, how to maintainstandards for confidentiality, record keeping, provision of quality care, and other issuesaffecting providers:Practitioner Credentialing, Contracting, RecredentialingFacility/Organization Assessment, Contracting, ReassessmentConfidentiality and Disclosure PolicyRecord Keeping StandardsClinical Practice GuidelinesNew TechnologiesSignificant Member Incident Reporting (Patient Safety)Provider Cultural CompetencyProvider BenchmarkingProvider SatisfactionProvider EducationProvider Advisory CommitteeProviders are encouraged to call the Provider Line at 1-888-251-2224 (available 24hours a day/seven days a week) for assistance.Practitioner RightsThe organization’s policies and procedures include the right of practitioners to:Review information submitted to support their credentialing application.Correct erroneous information.Receive the status of their credentialing or recredentialing application, upon request.Receive notification of these rights.III.A. Practitioner Credentialing, Contracting, RecredentialingFor a practitioner, credentialing is the first step in Community Care's qualitymanagement process to ensure that members receive high-quality, responsive, andculturally-competent care.Practitioners who wish to provide services to members must complete the credentialingprocess before they are eligible to contract to provide services to members. Thepractitioner credentialing process includes evaluations of the practitioner (such aslicensing) and the site where services are to be provided.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 58

III.A.1 Practitioner Credentialing ProcessA practitioner is credentialed on the date in which the Credentialing Committee reviewsand approves the candidate's completed application.The Credentialing Committee ensures that practitioners initially meet and continue tomeet Community Care’s criteria and standards for participation in the network. TheCredentialing Committee reviews practitioner credentials and information for initialcredentialing and thereafter at least every three years.The practitioner credentialing process involves the following major steps: Each credential (degrees, certifications, licenses) must be verified with primarysources (academic institution, certifying body, licensing board or agency, etc.). Each practitioner evaluating or treating children and adolescents under the age of 18must submit a Pennsylvania State Police Criminal Background Check (Act 34),Pennsylvania Child Abuse History Clearance (Act 33), and FBI Background Checkthat are no older than 1 year from the date of submission. Each practitioner serving older (age 60 and older) or care dependent adults mustsubmit a Pennsylvania State Police Criminal Background Check that is no older than1 year from the date of submission. The completed application (all credentials verified with primary sources) must bereviewed and approved within 180 days of the date the application was signed. Ifnot, the application must be refreshed with Community Care by returning a copy ofthe original application with a new attestation to the practitioner to review for anychanges or additions. This application must be returned to Community Care with anewly signed and dated attestation.Verifying credentials with primary sources is performed by the CredentialingDepartment. This includes a review of information on sanctions or limitations withMedicare, Medicaid or state licensing agencies (NPDB, Cumulative Sanctions Report,Federal State of Medical Boards (FSMB), etc.).All criteria must be met and verified to consider the application complete forcredentialing.III.A.2 Change in Practitioner InformationAny change to information submitted by a practitioner during the credentialing andcontracting process, or at any time thereafter, including information such as streetand/or suite address and telephone and/or facsimile numbers, must be communicatedto Community Care's Network Relations Department.To prevent problems such as interruptions of referrals, failure to receiveauthorizations for services, or denial of payment for services provided toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 59

members, practitioners are asked to call their designated Provider RelationsRepresentative through the Community Care Provider Line (1-888-251-2224) withany change to practitioner information at least 30 days in advance of any suchchange. The Provider Relations Representative will request written documentation ofthe change through the completion of an Attachment A form in order to process thischange in Community Care’s database.PLEASE NOTE: If a practitioner change involves adding or changing a contractservice or a site where services are provided to Community Care members, theaddition or change must be reviewed by the appropriate committee, and ifapproved, must meet recredentialing standards and a site visit may be required—before payment for services can be processed.III.A.3 Practitioner ContractingA practitioner may begin the contracting process after the practitioner completescredentialing by Community Care. Community Care seeks to contract with specificpractitioners to provide specific behavioral health services at specific sites (See theGuidelines for Obtaining Approval for In-plan Services at the beginning of this ProviderManual).Criteria considered for contracting include:The service needs of prospective members.The geographic and demographic distributions of members.The geographic distribution and cultural competencies of practitioners.Each practitioner's scope of services, capacity to serve members, andresponsiveness to quality issues.For any practitioner terminated from the network, up to a 60 day transition of care periodmay be initiated for Members under that Practitioner's care (See Section IV.E.3).III.A.4 Practitioner RecredentialingPractitioners must be recredentialed not more than three years from the date ofcredentialing/last recredentialing. The Credentialing Department will notify practitionersin advance when it is time to start the recredentialing process, which is similar to thecredentialing process with the additional consideration of quality information supplied bythe Community Care Quality Management Department. An application forrecredentialing is considered complete when it includes the following:Primary source verification of the practitioner’s credentials (such as any newdegrees or certifications since last credentialing/recredentialing, verification ofcurrent licensures, and malpractice and claims history).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 60

Provider Benchmarking (See Section III.I) including analyses of member complaints,Significant Member Incidents, and quality and/or compliance audits.All practitioners must be recredentialed before their expiration date. Failure to berecredentialed before the expiration date will result in termination of thepractitioner’s contract with Community Care and will prevent payment for anyservices provided after the expiration date.A practitioner whose credentials with Community Care have expired cannot beauthorized or paid for services provided after the expiration date. Because verifyingcredentials with primary sources requires a minimum of seven weeks and may take upto six months, Community Care's Credentialing Department sends applications forrecredentialing before each practitioner’s deadline. Practitioners are urged to start therecredentialing process as soon as the application is received. The CredentialingDepartment will remind practitioners periodically of application components that remainincomplete.III.B. Facility/Organization Assessment, Contracting, ReassessmentAssessment of a Facility (hospital, residential treatment facility, community mentalhealth center, clinic, partial hospitalization program, or any other organization providingbehavioral healthcare services in a community setting) is the first step in CommunityCare's quality management process to ensure that members receive high-quality,responsive and culturally competent care. A facility must complete this process in orderto be eligible to contract to provide services to Community Care members. Assessmentincludes evaluations of the facility (such as licensing) and the site where services are tobe provided. Community Care ensures that facilities initially meet and continue to meetCommunity Care’s criteria and standards for participation in the network. CommunityCare assesses facilities upon initial application and thereafter at least every three years.III.B.1 Facility/Organization AssessmentA facility is considered to have completed its assessment on the date the CredentialingSupervisor and Chief Medical Officer or designee reviews the candidate's completedapplication, verifies that all criteria have been met and signs the Facility AssessmentForm.The Facility assessment process involves four major steps:Credentialing staff confirms the facility’s licensure and facility’s accreditation, if any,and status or standing of the facility with state regulatory bodies.Each location where the facility will offer services to Community Care members must"pass" a site visit unless the facility is accredited by the Joint Commission onCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 61

Accreditation of Healthcare Organizations (JCAHO), Committee on Accreditation ofRehabilitation Facilities (CARF), or Council on Accreditation of Services for Childrenand Families (COA), OR supplies a complete licensing report from the appropriatelicensing entity to Community Care. If, after assessment, a facility adds a locationwhere Community Care services are to be provided and the new location has notbeen reviewed, a site visit may need to be conducted at this new location unless thesite has been reviewed by the accrediting agency or a complete licensing report hasbeen submitted. In lieu of a Community Care site visit, Community Care will accept acopy of the licensing site visit report indicating that the facility is in full compliancewith all of the licensing regulations/standards.During the site visit, documentation must "pass" the review of treatment recordkeeping practices, which may include review of a blinded or mock up treatmentrecord. The site visit includes a review of treatment record keeping practices.All facilities providing services to children and adolescents under the age of 18 musthave a policy in place requiring the Pennsylvania Child Abuse History Clearance,Pennsylvania State Police Criminal Record Check and FBI Background Check foremployees working with this population.All facilities providing service to Older (age 60 and older) and care dependant adultsmust have a policy in place requiring a Pennsylvania State Police CriminalBackground Check for those individuals who may have direct contact with thispopulation.The completed application (with all primary source verification completed, site visit(s)and treatment record keeping practices completed satisfactorily) must be reviewedand approved within 180 days of the date the application was signed. If not, theapplication must be refreshed with a newly signed authorization. To ensure that dataaccurately reflects current facility information, Community Care maintains the 180day standard to complete this process. In the event that this process shall exceed180 days, the facility will be sent a copy of the original application and be required tosign a new attestation to confirm that the data is accurate or indicate any changes inthe original information on the application.Primary source verification is performed by the Community Care CredentialingDepartment. Community Care Provider Relations staff conduct the site visit. Before thesite visit is scheduled, the facility will be given a copy of the Non-Accredited Facility OnsiteReview Form that lists the criteria for assessing/reassessing a site, such aspresence of fire extinguishers and handicapped-accessible restrooms. In addition,policies and procedures must be in place for a plan assessment of the provider’s abilityto provide urgent and routine care, to enroll additional patients in accordance withstandards adopted by Community Care and a policy or policy statement regardingcultural awareness and diversity competence.Included in the site visit is the review of treatment record keeping practices using theMedical Record Review Form, which is performed to assess the adequacy ofdocumentation/record keeping procedures.All facility criteria must be verified to consider the application for assessment complete.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 62

III.B.2 Change in Facility informationAny change to information submitted by the facility during the assessment andcontracting process or any time thereafter, including information such as mailingaddress and telephone and facsimile numbers, must be communicated to CommunityCare's Network Management Department. To prevent problems such as interruptions ofreferrals, failure to receive authorizations for services, or denial of payment for servicesprovided to members, facilities are asked to call their designated Provider RelationsRepresentative at least 30 days in advance through the Community Care Provider Line(1-888-251-2224) with any change to facility information.Community Care will request written documentation of the change through thecompletion of an Attachment A form so that all Community Care Departments can benotified of the change.PLEASE NOTE: If the facility change involves adding or changing a service or asite where services are provided to Community Care members, the addition orchange must be reviewed. If approved, a site visit may be required beforepayment for services can be processed.III.B.3 Facility ContractingA facility may begin the contracting process after the facility completes assessment byCommunity Care. Community Care seeks to contract with facilities to provide specificbehavioral health services in specific geographic locations (See the Guidelines forObtaining Approval for In-plan Services at the beginning of this Provider Manual).Criteria considered for contracting include:The service needs of prospective members.The geographic and demographic distributions of members.The geographic distribution and cultural competencies of facilities.Each facility's scope of services, capacity to serve members and responsiveness toquality issues.For any facility terminated from the network, up to a 60 day transition of care period—forroutine ambulatory services only—may be initiated for members under that facilityprovider's care (See Section IV.E.3).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 63

III.B.4 Facility ReassessmentFacilities must be reassessed not more than three years from the date ofassessment/last reassessment.The Credentialing Department will notify facilities in advance when it is time to start thereassessment process, which is similar to the assessment process with the additionalconsideration of quality information supplied by the Community Care QualityManagement Department. An application for facility reassessment is consideredcomplete when it includes the following:Credentialing staff confirms any new licensures, facility accreditation andcertifications, etc., since last assessment/reassessment, verification of currentlicensures, etc.Monitors of Facility performance (Provider Benchmarking, See Section III.I),including analyses of Member Complaints, Significant Member Incidents and Qualityand/or Compliance audits.All facilities must be reassessed before their expiration date. Failure to be reassessedbefore the expiration date will result in termination of the facility's contract withCommunity Care and will prevent payment for any services provided after the expirationdate. A facility whose assessment with Community Care has expired cannot beauthorized or paid for services provided after the expiration date.Because verifying credentials with primary sources requires a minimum of seven weeksand may take up to six months, Community Care's Credentialing Department sendsapplications for reassessment before each facility's deadline. Facilities are urged to startthe reassessment process as soon as the application is received. The CredentialingDepartment will remind facilities periodically of application components that remainincomplete.III.B.5 Termination of Provider from the NetworkCommunity Care may terminate a provider from the network without cause or withcause.III.B.5a Termination without CauseThe Provider Agreement may be terminated without cause by either party at any timeupon 90 days prior written notice to the other party. Such notice shall clearly state theeffective date of such termination. All terms and provisions of this agreement shallremain in effect until the effective date of termination except as otherwise provided.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 64

III.B.5b Termination with CauseAction to terminate a provider with cause may be initiated when Community Carebecomes aware of any of the following:Serious issue regarding the provider’s quality of care.Revocation or suspension of a provider’s license or other legal credential authorizingthe provider to practice in any state or jurisdiction.Revocation or suspension of Drug Enforcement Agency (DEA) registration orControlled Dangerous Substance (CDS) certificate.Professional review action by any state or jurisdiction issuing a professional licenseor any federal agency, professional organization, or other identified regulatoryorganization.Contractual violation, including, but not limited to:• Breach of confidentiality.• Failure to comply with terms of a corrective action plan.• Material misrepresentation of information on the provider application forcredentialing/recredentialing or assessment/reassessment.• Conviction of a felony.• Cancellation or failure to renew or maintain professional liability insurance in theamounts acceptable to Community Care.The Provider is notified in writing via certified mail of the action to initiate terminationwith cause, including the reason for this action. Included in this correspondence is anexplanation of the process to request an appeal of the decision to terminate with cause(See following Section III.B.6).III.B.6 Notification and Process to Appeal Adverse Determinations RegardingNetwork ParticipationProviders are notified in writing of any determination affecting their continuedparticipation in the provider network, including credentialing/recredentialing orassessment/reassessment, suspension of new referrals, or termination from thenetwork. This written notification will include the reason for the decision and anexplanation of the appeal process, if any.The appeal process is as follows:Within 30 days from the date of the notification, the provider must send a letter, fax,or email to the Community Care Chief Medical Officer (CMO) to request to appealthe decision.The CMO will schedule an Appeal Committee meeting to be held within 30 days ofreceiving the provider’s request.The provider will be informed of the date, time, and place of the meeting as well asthe provider’s right to be present at the hearing, to be represented by an attorney, toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 65

present relevant information, and to request a different date and time for the hearingshould the provider be unable to attend as scheduled.The provider will receive written notification of the Appeal Committee’s decisionwithin two business days of the date of the decision.The decision of the Appeal Committee is final.III.C. Confidentiality and Disclosure PoliciesCommunity Care has developed policies concerning confidentiality to guide CommunityCare staff and providers in collecting, using, and disclosing information that isnecessary and appropriate to provide high quality services efficiently, whether theinformation was created by Community Care or acquired in connection with ourbusiness activities. The confidentiality policies are intended to meet all requirements ofthe federal Health Insurance Portability and Accountability Act (HIPAA) and apply to, butare not limited to, all member information, provider information (includingcredentialing/assessment, contracting, and benchmarking) and quality managementprogram documents and meeting minutes.Confidentiality policies and procedures describe in detail how Community Care protectsmembers’ Rights and Responsibilities related to privacy in all settings (See SectionII.A), to know what information is routinely gathered about them and how it is used, toreview this information (including their medical records) and to authorize disclosure oftheir member identifiable information in special circumstances.The following sections highlight Community Care’s confidentiality policies andprocedures that may apply to providers (who are “contractors” of Community Care andmay also be “representatives” of Community Care).The topics regarding member identifiable information that are covered in the followingsections include:What constitutes member, provider and Community Care confidential information(Section III.C.1a).How to handle confidential information (Section III.C.1b).How to maintain confidentiality when transferring information by mail, fax, and email(Section III.C.1c).Destroying confidential information (Section III.C.1d).Collecting and using member identifiable information (Section III.C.2).Informing members about confidentiality (Section III.C.3).Who is able to give informed authorization for release of member identifiableinformation (Section III.C.4).Member access to utilization records (Section III.C.5).Disclosure of member identifiable information, including disclosure withoutauthorization of the member/member representative, validity of authorization andverbal authorization for release of information (Section III.C.6-7).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 66

Community Care’s requirements for provider storage and transmission (by email orfax) of member identifiable information (Section III.C.8).Community Care’s policy on confidentiality describes for Community Care employees,representatives (including providers), and members, our policies and procedures onobtaining authorizations for use of member medical information, allowing membersaccess to their medical records held by providers and protecting access to member“protected health information” as defined by HIPAA.III.C.1 General Confidentiality ProvisionsCommunity Care agents and contractors (including providers) potentially having accessto confidential information are required to sign Community Care’s Statement ofConfidentiality agreeing to be bound by Community Care’s strict confidentiality policiesand procedures, or must conform to equivalent provisions as determined by CommunityCare staff or legal counsel. Breach of the Statement of Confidentiality or equivalent isgrounds for immediate termination with cause (See Section III.B.5).III.C.1a What Constitutes Confidential InformationThe following are highlights of what constitutes confidential information:Member identifiable data and information, including explicitly identifiable data suchas member name, social security number, or other identifier that can be directlylinked to a specific individual and implicitly identifiable data such as memberaddress, telephone number, date of birth, or other information that, alone or incombination with other available information, can lead to identification of a specificindividual, are confidential.Data and information specific to practitioner providers, including but not limited to,that used for network development, credentialing, performance evaluation, qualityassurance, quality improvement, and peer review are Confidential. A practitionerprovider’s name, professional degree, status as a member of Community Care’spractitioner provider network, business address, business telephone number andspecialty/specialties or self-identified areas of special interest are not consideredconfidential when disclosed for legitimate business purposes. Data and informationrelated to a practitioner provider’s racial, cultural, or ethnic background, age,religious affiliation, gender and ability to communicate in languages other thanEnglish, are Confidential unless the practitioner provider explicitly authorizes therelease of this information. For example, completing optional sections of theprovider credentialing/recredentialing or assessment/reassessment applicationregarding a provider’s ability to communicate in languages other than English maybe used to help fulfill members’ requests when making referrals.Information specific to a practitioner practice group or facility, including but notlimited to, that used for network development, organizational assessment andCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 67

contracting, performance evaluation, quality assurance, and quality improvement, isConfidential. However, a practitioner practice group or facility name, status as aparticipant in Community Care’s network, business address, business telephonenumber, and services offered are not considered confidential when disclosed forlegitimate business purposes.Community Care’s business data and information, including but not limited tosalaries, policies and procedures, finances, business plans, information aboutproviders participating in the network when not being released for legitimatebusiness purposes, proposals to potential or current customers, informationdisclosed to Community Care in confidence by any third party, and performanceevaluation, quality assurance, and quality improvement data and information whereproviders are individually identifiable are Confidential.III.C.1b Keeping Information ConfidentialFor all Community Care representatives:• Divulging computer passwords and security system pass codes is prohibited• Divulging access codes and keys with any individual who does not have the rightto such access codes or keys is prohibited.• All computers that have the ability to access confidential data or information mustbe protected with a confidential log-in password; turned off or logged off at theend of the workday; and protected with a confidential screen-saver password inthe event that the computer is turned on and logged on while the computer useris away from his or her work area.Community Care’s agents, contractors (including providers), employees, staff, andvolunteers may not access or view confidential data or information unless requiredby their duties or responsibilities for, or on behalf of, Community Care.Community Care’s agents, contractors (including providers), employees, staff, andvolunteers may not discuss confidential data and information in an area whereindividuals, including other Community Care agents, contractors, employees, staff,and volunteers who do not have the right to know about the information, mayoverhear the information.All confidential data and information must be maintained in a manner that preventsaccess by individuals who do not have a right to access the data and information.All physical media, including but not limited to, paper, magnetic and optical, used tostore confidential data and information must be stored under a double-lock system.All physical media containing confidential information that are still in use byCommunity Care agents, contractors (including providers), employees, staff andvolunteers at the end of the day must be locked in that individual’s desk or in anothersecured storage area. All desks or secured storage areas must be in areas withkeyed entry, maintaining a minimum of a dual-key system. All physical mediacontaining confidential information that are no longer needed by Community Careagents, contractors, employees, staff and volunteers must be returned to lockedmaster storage at the end of the day. All electronic media containing confidentialinformation must be password-protected.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 68

III.C.1c Transferring Confidential InformationThe transfer of confidential information for legitimate business purposes betweenCommunity Care’s agents, contractors (including providers), employees, staff, andvolunteers in their official capacities as representatives of Community Care isconsidered an internal transfer, even though they may be in different physical locations.The transfer of confidential information other than to Community Care’s agents,contractors, employees, staff, and volunteers in their official capacities asrepresentatives of Community Care is considered an external transfer and must bemade in accordance with Community Care’s Authorization to Disclose Information (SeeSection III.C.6). The internal transfer of all confidential data and information must be conducted in amanner that limits potential access by individuals who do not have a right to accessthe data and information. When not hand-carried and personally delivered to therecipient, physical media containing confidential data and information must beplaced in a sealed envelope marked “Confidential.” Confidential data and information sent by facsimile must bear a prominentconfidentiality notice similar to the following: “This facsimile transmission containsconfidential and privileged information for use only by the intended recipient. Do notread, copy, or disseminate this material unless you are the intended recipient. If youbelieve you have received this message in error, please notify the sender byfacsimile or telephone and destroy this document.” Confidential data and information sent by email must be flagged as confidential andbear a confidentiality notice similar to the following within the message: “This emailcontains confidential and privileged information for use only by the intendedrecipient. Do not read, copy, or disseminate this material unless you are theintended recipient. If you believe you have received this email in error, please notifythe sender by return email, securely delete this file and any electronic or magneticcopies and destroy any paper copies.”III.C.1d Destroying Confidential InformationConfidential data and information no longer required for legitimate business purposesmust be destroyed in a secure manner. Paper records must be thoroughly shredded.Magnetic files must be deleted in a manner that does not permit the files to beundeleted, for example, by reformatting a floppy disk using the “secure” format option.Either optical storage media must have the files securely deleted or, if this is notpossible, the storage media must be destroyed.III.C.1e Committee Oversight of ConfidentialityCommunity Care’s privacy officer and the Compliance Department are responsible forapproving and periodically reviewing all policies and procedures related toconfidentiality and for identifying, developing and implementing mechanisms to overseeCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 69

the implementation and application of Community Care’s confidentiality policies andprocedures.Highlights of this department’s responsibilities include the following:At least annually, the department and privacy officer will evaluate ways to (1) reducethe collection of member identifiable data and information and (2) aggregate or deidentifysuch data and information as close to the collection point as possible, asidentified by surveying Community Care representatives, holding brainstormingsessions with Community Care representatives and evaluating complaints.The privacy officer is responsible for reviewing and approving information given tomembers, including information about Community Care’s confidentiality policies andprocedures.Community Care has identified circumstances necessitating special protection ofmember identifiable data and information and these are described in the policy andprocedure “Handling of Member Identifiable Information.” Requests for specialprotection of member identifiable information are referred to the privacy officer, whowill consider the request, determine whether it should be honored and notify therequestor of the decision. If the request is honored, the privacy officer will determinethe mechanism to adhere to the request and update the procedure “InternalHandling of Member Identifiable Information” to reflect the addition. If the privacyofficer determines not to honor the request, the requestor will be notified of his or herright to appeal the decision through Community Care’s appeals process.All member and provider concerns regarding confidentiality shall be logged ascomplaints and processed through Community Care’s complaint and appealsprocess.The privacy officer along with the Chief Medical Officer, reviews requests for accessto member identifiable data and information from all sources, internal and external.In determining the timeframe in which to conduct the review, the Chief MedicalOfficer will consider the potential benefit to members of allowing requested access todata and information. When deciding whether or not to honor the request for accessto such data and information, the Chief Medical Officer will weigh the potentialbenefit and risks to members.The Chief Medical Officer is responsible for reviewing all requests for access toconfidential data and information for research purposes.III.C.2 Collecting and Using Member identifiable InformationCommunity Care collects and uses member identifiable data and information routinely inthe performance of its work. Purposes for which data and information are routinelycollected include:Verification of member eligibility for services.Management of behavioral health benefits, including prospective, concurrent, andretrospective reviews and decisions regarding coverage for requested treatment.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 70

Coordination of care.Billing.Adjudication of claims.Performance measurement and improvement (“quality assurance”).Compliance audits.Prevention and disease management activities.Provider credentialing.Investigating and resolving inquiries and complaints.Processing appeals.Complying with regulatory requirements and accreditation standards.Community Care is responsible for notifying members of Community Care’s routinecollection and use of member identifiable data and information for the purposes justdescribed. The use of member identifiable information for purposes other than thoselisted requires written authorization from the member or representative, unless use ofthe information is permitted or required by applicable law or a valid court order.III.C.3 Informing Members about ConfidentialityCommunity Care prepares information for members that describes Community Care’sconfidentiality policies and procedures. This information covers key points of theinformation contained in Community Care’s Confidentiality Policy, such as:Collecting and Using member identifiable Information.Handling of member identifiable Information.Ability to give informed authorization.Member access to utilization records.Disclosure of information.An accounting of disclosure of member protected health information (PHI) tomembers.Amending PHI by the member.Information about confidentiality is disseminated to members in:Member “Rights and Responsibilities.”Member instructions on how to obtain care, appeal a coverage decision, and accesscustomer services support.The member complaint process.Information about confidentiality is sent to members annually via member newslettersand in the Member Handbook. Community Care’s Notice of Privacy is also posted onour website at http://www.ccbh.com/privacy.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 71

III.C.4 Ability to Give Informed Authorization for Release of Member IdentifiableInformationCommunity Care obtains special authorization from members or representatives torelease member identifiable information, as described in the procedure for Disclosure ofInformation (See Section III.C.6). Community Care has made the followingdeterminations regarding the giving of valid authorization for the release of memberidentifiable health information:A member who has reached the age of majority as identified by Community Care’seligibility data is capable of giving informed authorization for release of informationon his or her own behalf unless Community Care has received notification that themember has been adjudicated incompetent.The natural or adoptive parent of a minor member, as identified by CommunityCare’s eligibility data, is capable of giving informed authorization for release ofinformation on behalf of the minor member unless Community Care has beeninformed that the parent has been adjudicated incompetent, the parent is not thelegal guardian of the minor member, or the minor member has been legallyemancipated.An emancipated minor member is capable of giving informed authorization on his orher own behalf. If not already on file with Community Care, Community Care willrequest proof of the minor member’s status from the minor member before honoringthe authorization for release of member information.Community Care expends all reasonable effort to develop and maintain an accurate andefficient system for identifying who is eligible to give valid authorization for release ofmember identifying information. Having established such a system, Community Carereasonably relies on the absence of information indicating that a member or parent of aminor member has been adjudicated incompetent or that a parent is not a minormember’s legal representative, for accepting an authorization for release of informationas valid. Verifying that a member or parent of a minor member is competent wouldplace an undue burden on Community Care and in most instances would require abreach of confidentiality.When Community Care is informed that a member is unable to give specialauthorization for the release of information, Community Care will accept authorizationfrom and/or release records to, a representative legally authorized to approve(authorize) the release of, or to receive, a member’s personal health information.Community Care requires written proof of the individual’s status as a legally authorizedrepresentative of the member and that the status as a legally authorized representativecovers the area for which the authorization for information is being sought.Individuals capable of giving valid authorization for the release of member identifiablehealth information are also entitled to have access to that information, except thatparents or guardians of children age 14 years or over may not have access to thechild’s health information without the authorization of the child.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 72

III.C.5 Member Access to Utilization RecordsIn accordance with HIPAA Section 164.524, members may request to access theirutilization file. The member may request to view his/her information by contactingCommunity Care. Community Care will coordinate the processing of the request. Theprivacy officer will respond to the request within 10 days. The process for requestinginformation is outlined in Community Care’s Confidentiality Policy.III.C.6 Disclosure of Member identifiable InformationCommunity Care requests authorization from the member or member’s legallyauthorized representative before disclosing member identifiable data or information(except as described in the procedures for “Collecting and Using Member identifiableInformation” (See Section III.C.2) and “Disclosure Without Authorization of Member toMember Representative” (See Section III.C.6a)). The member or the member’s legallyauthorized representative has the right to deny the request to release memberidentifiable information without consequence for the member or the member’s coverage.If member identifiable data and information are to be disclosed for purposes other thandescribed in the procedures for “Collecting and Using Member identifiable Information”(See Section III.C.2) and “Disclosure Without Authorization of Member or MemberRepresentative” (See Section III.C.6a), the authorization of the member or member’slegally authorized representative is required.Times when authorization of the member or member’s legally authorized representativeis required include:Before disclosing member identifiable data and information for research purposes.Before disclosing the member’s behavioral health signs, symptoms, diagnoses, ortreatment to a primary care physician (PCP) or other clinician not providingbehavioral health care to the member.When disclosing the member identifiable data and information that could foreseeablyresult in the member being contacted by another organization for marketingpurposes.Whenever member identifiable information is disclosed, only that information necessaryto accomplish the purpose of the disclosure is released.III.C.6a Disclosure without Authorization of Member or Member RepresentativeMember identifiable information can be disclosed without authorization of the memberor the member’s legally authorized representative in the following circumstances:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 73

When such disclosure to health care personnel, a health care facility, the member’sidentified significant other or the police is required to prevent loss of life or injury tothe member.When authorized by an appropriate and valid court order.When authorized by Community Care’s legal counsel to meet the requirements ofany applicable state or federal law.To report child abuse or neglect.To meet public health reporting requirements.To the Pennsylvania Department of Health, Pennsylvania Department of PublicWelfare and the Pennsylvania Insurance Department for the monitoring of healthcare systems, government programs, and compliance with civil rights laws.To federal officials for intelligence, counterintelligence, or other national securityactivities authorized by law.When required by Protective Services for the President and others.To military command authorities in order to provide medical information about amember serving in the armed forces.When it concerns Workers Compensation.To coroners and medical examiners.Information about inmates of a correctional institution or under the custody of a lawenforcement official may be released to that institution or official.III.C.6b Validity of Authorization to Release Member InformationCommunity Care considers an authorization to release member identifiable informationto be valid only if all of the following are met:The member or member’s legally authorized representative is informed of thespecific information to be released and the purpose(s) of the release in languagewhich he/she can understand.The member or member’s legally authorized representative is informed that theprovision of care or treatment will not be affected by the decision of the member ormember’s legally authorized representative.The authorization is obtained in a manner that complies with applicable laws andregulations.III.C.6c Written and Verbal Authorization for Release of InformationThe authorization to release information should be in writing. However under somecircumstances it may be necessary to obtain authorization verbally. The use of a verbalauthorization should be approved in advance by Community Care’s legal counsel or, ifcircumstances indicate the need for a rapid decision about the acceptability of a verbalauthorization, by a member of Community Care’s senior management. The writtenauthorization must include provision of the following information:The name of the person or entity providing the information.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 74

The specific information to be released.The purpose for the release.The individual or entity authorized to receive the information.The expiration date of the authorization.The signature of the member or member’s legally authorized representative.The address of the member or member’s legally authorized representative.The signature of the witness.The date of the authorization.Two representatives of Community Care (such as employees, staff, or practitionerproviders) must witness the entire process of obtaining verbal authorization to releaseinformation.III.C.7 Handling of Practitioner-specific InformationCommunity Care considers practitioner specific data and information, including but notlimited to, that information used for network development, credentialing/assessment,performance evaluation, quality assurance, quality improvement, compliance audits andpeer review, to be confidential to the extent permitted by law.A practitioner’s name, professional degree, status as a member of Community Care’spractitioner network, business address, business telephone number and specialty (ies)or self-identified areas of special interest are not considered confidential when disclosedfor legitimate business purposes.Data and information related to a practitioner’s racial, cultural, or ethnic background;age; religious affiliation; gender; and ability to communicate in languages other thanEnglish is confidential unless the practitioner explicitly authorizes the release of thisinformation. For example, if the practitioner volunteers the information on thecredentialing/assessment form that the practitioner has the ability to communicate inlanguages other than English, this information may be used by Community Care tomeet specific member needs or requests when making referrals.Regarding files of practitioner information maintained at Community Care: Physical files are maintained in a locked room or locked file cabinet when not beingused by credentialing staff or the Credentialing Committee. Practitioner files stored in electronic, magnetic, or optical format are protected with asecure password. Access to practitioner files is limited to credentialing staff, Credentialing Committee,network management staff, and the compliance staff. Upon request, practitioners may review information in their file, except for anyinformation from the National Practitioner Data Bank (NPDB). Review of NPDBinformation is prohibited by federal statute.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 75

Practitioners are informed of the right to review information in their file through thecover letter in the application packages for credentialing/recredentialing orassessment/reassessment.Practitioners may obtain a copy of their file by making the request in writing.Credentialing staff will send a copy of the practitioner’s file, marked “Confidential,” tothe practitioner within 10 business days of receipt of the written request for the file.NPDB information and peer review (peer reviewer) information is not included in thefile sent to the practitioner.Practitioners are notified by Credentialing staff of any information obtained duringcredentialing/recredentialing or assessment/reassessment activities that variessubstantially from the information provided by the Practitioner.Practitioners have the right to correct erroneous information by submitting corrections inwriting or sending additional documents to the Credentialing Department. Credentialingstaff document the verbal information or corrections provided by the practitioner,including the date and signature of the individual obtaining the information.III.C.8 Provider ConfidentialityCommunity Care providers are responsible for maintaining confidentiality in thecollection, use, and disclosure of member identifiable information. Requirements are asfollows:Member identifiable data and information (such as medical records, appointmentbooks, correspondence, laboratory results, billing records and treatment plans),whether paper-based or on removable electronic data storage media, must bemaintained under lock and key, either in locked cabinets or in a locked area. Thedata storage area must be separate from public areas such as waiting rooms, areaswhere services are delivered and any other areas accessible to unauthorizedpersons. When unlocked, paper records and removable computer storage mediamust be maintained in a secure location where they are not accessible and theircontent is not visible to unauthorized individuals.When computers are used to store member identifiable information, they must bepassword-protected (unless all persons at the site are authorized access and thecomputers are in secure locations not accessible to unauthorized individuals).Computer monitors must be positioned such that they are not visible to unauthorizedindividuals.If electronic mail (email) is used to transmit member identifiable data or information,the email must be flagged as confidential and a confidentiality notice must beprominently displayed at the beginning of the email that conveys a messagesubstantively similar to the following: “This email contains confidential and privilegedinformation for use only by the intended recipient. Do not read, copy, or disseminatethis material unless you are the intended recipient. If you believe you have receivedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 76

this email in error, please notify the sender by return email, securely delete this fileand any electronic or magnetic copies and destroy any paper copies.”Telefacsimile (fax) machines must be located where faxes may not be intercepted orviewed by individuals not authorized to access member identifiable information.When member identifiable information is transmitted by fax, a confidentiality noticesimilar to the following must be prominently displayed on the cover sheet: “Thisfacsimile transmission contains confidential and privileged information for use onlyby the intended recipient. Do not read, copy, or disseminate this material unless youare the intended recipient. If you believe you have received this message in error,please notify the sender by facsimile or telephone and destroy this document.”Please call the Provider Line (1-888-251-2224) for any authorization for release ofinformation forms that might be needed in the care of members.III.D. Record Keeping StandardsCommunity Care has established treatment record documentation guidelines,performance goals, and standards for availability of treatment records to facilitateaccurate record keeping, communication between practitioners and coordination andcontinuity of care within the behavioral health continuum and the medical deliverysystem. Community Care expects providers to implement these treatment recorddocumentation guidelines.Each member’s medical record must meet the following standards:The member address, employer or school, home and work telephone numbers,emergency contacts, marital/legal status, authorization forms, and guardianshipinformation is documented, as relevant.The member's name or identification number is present on each page.The responsible clinician's name and professional degree are documented.All entries are dated.The record is legible.Relevant medical conditions are listed, prominently identified, and updated.Presenting problems and relevant psychological and social conditions affecting themember's medical and psychiatric status are documented.Special status situations such as imminent risk of harm, suicidal ideation, orelopement potential are prominently noted, documented, and updated in compliancewith written protocols.Past medical and psychiatric history is documented, including previous treatmentdates, provider information, therapeutic interventions and responses, sources ofclinical data, relevant family information, results of laboratory tests, and consultationreports.Allergies and adverse reactions are clearly documented.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 77

Medication(s) that have been prescribed, dosages of each medication and the datesof initial prescription and of any changes in medication regimen.Current version of DSM diagnosis on all five axes (I, II, III, IV, and V) is documented.Complete developmental history is documented for children and adolescents.The following are documented:• Symptoms• Mental status• Member strengths and limitations• Compliance with treatment plan• Compliance with medication regimen, if appropriate• If the member has drug and alcohol issues (past and/or present), the results ofthe provider's inquiry as to the welfare of children and significant others living inthe home• Progress towards treatment goals• Coordination of care information, as applicable• Date of next session• Discharge planCommunity Care expects providers to maintain an organized treatment record keepingsystem. The following elements are required components of an organized recordkeeping system.A unique treatment record for each member.Treatment record notes maintained in chronological or reverse chronological order.An organized system for maintaining documents for each member; for example, alldiagnostic reports maintained together in a section of the folder.An organized filing system that provides easy access to unique member files.Consent to release information and informed consent documentation as appropriate.Treatment record documentation occurs as soon as possible after the encounterwith special status situations, such as imminent harm, suicidal ideation, orelopement potential prominently noted.Community Care expects all practitioners and facilities to provide treatment to membersin a safe environment. All providers should assess a member for suicidal ideation andhomicidal ideation throughout a member’s treatment. If a member is being treated in anoutpatient setting and expresses suicidal or homicidal ideation, the provider should takethe appropriate actions to ensure that the member and others are safe, such asfacilitating an inpatient hospitalization admission.Upon admission for an inpatient psychiatric hospitalization, the initial evaluationcompleted by the facility psychiatrist should clearly document that the member wasassessed for both suicidal and homicidal ideation. Additionally, members should beassessed for suicidal and homicidal ideation on an ongoing basis to ensure themember’s safety, as well as the safety of others. Providers should also proceed with aDuty to Warn if indicated.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 78

When a member is discharged from an inpatient hospitalization stay, a crisis planshould be developed by the facility and reviewed with the member upon discharge. Thecrisis plan should also include the phone number of the appropriate county services formental health emergencies.All medical records and reports completed by the provider for Community Caremembers are to be available, as appropriate, to practitioners and staff other than thetreating practitioner; Community Care; the Centers for Medicare and Medicaid Services(CMS; formerly the Health Care Financing Administration (HCFA); National Committeefor Quality Assurance (NCQA); or Pennsylvania Department of Health, licensing body,or regulatory agency; or other agencies as required by applicable law and regulations,for at least seven years after the initial date the provider delivered health care servicesto the member under contractual agreement with Community Care, regardless oftermination of the contractual agreement.The review of treatment record keeping practices, using a Medical Record Review Formis one component of the provider’s credentialing site visit. Facilities not accredited bythe Joint Commission on Accreditation of Healthcare Organizations (JCAHO),Committee on Accreditation of Rehabilitation Facilities (CARF), or Council onAccreditation of Services for Children and Families (COA) must meet the recordkeeping standards established by Community Care. Record keeping must also meet alllicensing regulations. The provider is sent the Medical Record Review Form instrumentprior to the scheduled site visit.The provider may prepare for the medical record review by designating an actualtreatment record for review, preparing a blinded treatment record, or preparing a mocktreatment record for review. The purpose of the credentialing medical record review is toensure that the provider has resources in place to collect the information neededthrough all stages of evaluation and treatment. A score of 80% is required to pass themedical record review. Providers are notified in writing if the score is below passing.When the score is below passing, the provider must submit a written corrective actionplan. A follow-up medical record review will be scheduled within six months to monitorimplementation of the provider’s corrective action plan.In addition, quality staff assess completeness of treatment records by using one or moreof the following methods:Reviewing a sample of treatment records on-site at the practitioner’s office.Obtaining a sample of treatment records from practitioners via mail or fax toCommunity Care.Reviewing treatment records sent to Community Care for other reasons.Community Care’s performance goal for completeness of treatment recorddocumentation is 80%. Aggregate results of the assessment of treatment recorddocumentation are communicated periodically to providers.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 79

III.E. Clinical Practice GuidelinesCommunity Care utilizes clinical practice guidelines to help practitioners and membersmake decisions about appropriate health care for specific clinical circumstances. Theseevidence-based guidelines are reviewed annually, updated as appropriate, andapproved by Community Care’s Quality and Care Management Committee (QCMC) andBoard Quality Improvement Committee (BQIC). Annually, Community Care measuresperformance against each of the clinical practice guidelines via claims data or recordreviews. Providers are notified of the results of these measurements via providernewsletters or web-based communications. Currently, the following guidelines are beingutilized:American Psychiatric Association Practice Guideline for the Treatment of Patientswith Major Depressive Disorder (Third Edition), October 2010.National Institute on Drug Abuse (NIDA) Principles of Drug Addiction Treatment: AResearch-Based Guide (Second Edition), April 2009.In addition to these to Clinical Practice Guidelines, Community Care adopted the APAPractice Guideline for the Treatment of Patients with Schizophrenia (Second Edition –April 2004) as well as the APA’s Treating Schizophrenia – A Quick Reference Guide.To obtain a copy of the APA guidelines, contact the American Psychiatric Association,1400 K Street NW, Washington, DC 20005 or visit the website:http://psychiatryonline.org/guidelines.aspxTo obtain a copy of the NIDA guideline, contact the National Institute of Drug Abuse,National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD20892. The guideline may also be obtained via the NIDA website at:http://www.nida.nih.gov/PODAT/PODATIndex.html.For information about our practice guideline measurements, contact Community Care at1-888-251-2224.III.F. New TechnologiesCommunity Care provides for a systematic assessment of new technologies and newapplications of existing technologies for behavioral health care, including clinicalinterventions, procedures, devices, and certain types of pharmacological treatments.Community Care’s New Technology Subcommittee, chaired by the Chief MedicalOfficer, meets on a routine basis to consider new technologies proposed for inclusion inCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 80

a benefits package. In those instances in which Community Care does not make thefinal decision on the inclusion or exclusion of a technology in the benefits package,Community Care assesses the new technology and makes a recommendation to theappropriate decision-making body.III.G. Unusual Incidents/Significant Member Incident Reporting (Patient Safety)A Significant Member Incident (SMI) or sentinel event is an unexpected and undesirableoutcome that has an adverse impact on the outcome of care. The detail of each SMI ispromptly reviewed to determine needed follow-up and to coordinate communicationbetween Community Care, the provider, and county agencies, as appropriate, to avoidunnecessary duplication of reports.Community Care receives information about SMIs in various ways. Examples of waysinformation about SMIs are received include staff, practitioner, provider, member,governmental reports, and publications.SMIs include but are not limited to:Completed suicides.Severe suicide attempts/self inflicted injury.Apparent serious physical accidents/suspicious deaths.Adverse effects of medications requiring medical intervention.Member injury due to restraint/seclusion.Apparent homicide or serious physical assault by client.Life threatening injury or illness while on provider site requiring hospitalization.Sexual/physical abuse complaint by member against provider.Sexual abuse/physical assault complaint incurred by member at provider site.Failure to follow mandated Childline reporting requirements.Elopement.Any fire requiring emergency services of the fire department.Arrest of a member active in treatment.Providers must report these events within 24 hours of the incident occurring or within 24hours of the provider learning of the incident. Providers may report SMIs by calling theProvider Line (1-888-251-2224), calling their designated care manager at CommunityCare, or faxing the incident report to the Quality Management Department at 1-888-249-5646. The provider is to inform Community Care when they become aware of any lossof life during treatment or within 30 days of treatment. Providers are also expected tocomply with all applicable state and federal laws and professional and legalrequirements regarding reporting of SMIs. Providers should report all cases ofsuspected child or elder abuse that involve a Community Care member to theappropriate agency as defined by law, as well as to Community Care.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 81

Community Care has developed a plan for identifying SMIs that ensures prompt reviewof the detail related to each incident and determining needed follow-up. This processcoordinates communication between the provider, Community Care, the county, and theoversight agency. As a result, duplication of reports is minimal and further contact withthe provider specific.The individual receiving information about a SMI initiates the Significant MemberIncident Form and enters the information into a database. The data elements include ata minimum the:Date information about when the SMI is received.Date SMI occurred.Member name and identification number.Provider name and contact number.Nature of the incident.All SMIs are forwarded to the quality clinician, SMI coordinator within one business dayof the date the information became known to Community Care. The quality clinician,SMI coordinator:Reviews the issue thoroughly and determines the urgency of the SMI.Determines the appropriate individual to investigate the SMI.Notifies the Chief Medical Officer (CMO) or designee about the SMI (eachoccurrence of unexpected and undesirable outcome that has an adverse impact onthe outcome of care must be thoroughly reviewed by the CMO or designee).Documents all information and actions on the Significant Member Incident Form.Contacts the provider or others as needed.Obtains additional information, as needed to conduct a thorough investigation of theSMI, including any aspects of clinical care and safety involved.Obtains the medical records from the provider, if necessary.Conducts an office site visit if needed for issues such as office safety.Tracks the SMI to resolution.Prepares a written report of the findings of each SMI review including anyrecommendations.Forwards a copy of the completed SMI investigation results to the county/oversightagency when indicated.Identifying and monitoring SMI is part of quality improvement activities, whichCommunity Care performs as part of our comprehensive provider evaluation process(CPEP). Community Care directs any media inquiries regarding SMIs to the SeniorDirector of Quality Management and informs all other members of senior managementat Community Care of the incident.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 82

Providers are expected to report all cases of child abuse to the appropriate reportingagency as defined by law. They are also expected to report this to Community Carewhen it involves one of our members. We track this through our SMI reportingmechanisms. The provider may report this either verbally or in writing. ThePennsylvania Childline phone number is 1-800-932-0313.Orientation and ongoing provider education concerning this policy occurs through theprovider manual, provider education and training processes, and on a one-to-one basis,as necessary with providers. SMIs that are considered serious are contained in theprovider benchmarking review for recredentialing purposes. This process is a part of thecomprehensive provider evaluation process (CPEP) and includes monitoring providerstandards of practice as well as their timely response in addressing incidents identified.III.H. Provider Cultural CompetencyAs stated in Section I.B, Community Care has a vision for an effective and accessiblesystem of behavioral health care that requires providers to be culturally competent. Toenhance cultural competency of network providers, Community Care:Assesses providers’ cultural competency.Presents a training session for providers in principles of cultural competence.Has developed outcomes measures related to the care provided in a culturallydiverse system.Assessment of cultural competency includes evaluation of the diversity of providers inthe network and their documentation of all member informational materials (includingaudiovisual materials, training documents, service pamphlets and radio or televisionpublic service announcements).Cultural competency is demonstrated by:Documentation that multi-linguistic populations have access to appropriatetranslators and, when a predetermined percentage of Community Care’smembership speaks a language other than English, to appropriate multi-linguisticwritten member materials.Documentation that member materials address the needs of special-servicepopulations.Documentation that materials are culturally sensitive and appropriate to the memberaudience.Providers’ cultural competency is evaluated using instruments and methods that areconsistent with cultural patterns and norms of the members being served. Theinstruments vary according to the specific cultural groups being surveyed. However, allinstruments evaluate whether the provider understands the culture of the communityCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 83

eing served and uses strategies to avoid breakdowns and pitfalls due to culturalinsensitivity in the provision of care. The Quality Management Department reviews allcomplaints received related to cultural competency of providers, conducts trendanalyses, and determines appropriate follow-up when needed. Providers’ commitmentis essential to our ongoing development of a responsive system of care.III.I. Comprehensive Provider Evaluation Process (CPEP)Community Care believes that a successful partnership with providers includescollaboration between Community Care and our provider network to improve the clinicaland quality care delivered to HealthChoices members. Community Care employsseveral methods to evaluate providers to ascertain and improve the quality of careprovided to members through the provider network. This process can only beaccomplished through the involvement, participation, and collaboration of providers. Italso ensures that Community Care begins this quality assessment from the time ofapplication for network inclusion. Quantitative and qualitative performance data arenecessary for a useful system of comprehensive provider evaluation.Goals of the CPEP include:Ensuring that every provider (both individual practitioners and facilities) is providingcare to members, which meet best practice clinical and quality standards.Ensuring providers’ care meets access standardsEnsuring that every provider is culturally competent to provide services to membersStriving to continually improve the practice standards of the provider network in bothurban and rural areas.Utilizing both qualitative and quantitative measures to provide feedback to providers,county (ies), oversight entities, OMHSAS, and other stakeholders to ensureappropriate care.Identifying areas for improvement with subsequent opportunities for correctiveaction.Identifying individual provider clinical practices in comparison to other providers.Ensuring a safe and healthy environment for members with appropriate attention tofamily/significant other involvement.Ensuring that providers practice within an environment conducive to recovery andresiliency principles.Obtaining feedback from members, families, and other stakeholders through avariety of forums.Providing select information to members, families, and other stakeholders.In addition, the CPEP creates opportunities for providers to: Internally monitor themselves. Review claim reports about service activity.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 84

Review claim reports compared to aggregate claims reports of like providers.Identify trends.Improve the safety of their clinical environment.Participate in the resolution of member complaints.Promote appropriate family involvement.Ensure financial stability within their organizations.Promote their internal processes within a quality improvement framework.Establish policies that support performance standards and quality of care issues.Promote best practices.Review current practices with other providers.Implement evidence based practices.The overall comprehensive provider evaluation process consists of several methods ofevaluation to meet the stated goals.These methods include:Credentialing/Facility Assessment and ongoing Recredentialing/FacilityReassessment.Compliance with Community Care Performance Standards.Compliance with IPRO data collection and improvement processes.Compliance with Evidence Based Practices.Evidence from medical record reviews.Trending of Significant Member Incidents (SMIs).Demonstrated compliance with mental illness/substance abuse (MISA) screenings,coordination of care standards, and domestic violence screenings.Evidence of compliance with submission of requested reports including BHRSreporting.Timely return of quality improvement plans.Cooperation with Consumer/Family Satisfaction Teams and interventions related tomember concerns.Claims-based Provider Benchmarking Reports.Complaint trends.Grievance trends.Licensure status change (Provisional).Identification of provider performance incidents, e.g., lack of adequate dischargeplanning, late submission of BHRS packets.Overall compliance with provider network contract.Results of Fraud, Waste and Abuse Department visits.The CPEP is the responsibility of the Provider Relations/Network Development, CareManagement, Customer Service, Quality Management, Provider Reimbursement, andCompliance Departments of Community Care and is managed through quality. Datafrom each method may occur at various times throughout the year, and providerCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 85

dialogue and intervention may occur when trends are identified. Specific providerinformation is retained through the Quality Management Department. Community Careprovides feedback, through various quality activities to providers on an ongoing basis. Inaddition, Community Care analyzes aggregate network performance, makinginformation available to providers through articles, committees, public forums, andindividual provider meetings or site visits.Certain information identified as a result of the comprehensive provider evaluationprocess related to individual providers may fall under protected, peer reviewed, andprivileged information and will not be shared publicly. This information, however, will beshared with specific Community Care county contractors and OMHSAS.III.J. Provider SatisfactionProvider satisfaction is important to Community Care and we have multiple ways inwhich providers can express both their satisfaction and dissatisfaction with ouroperations.We contract with an outside survey company to conduct an Annual Provider SatisfactionSurvey. The survey tool is designed to assess provider satisfaction in a variety of areasincluding (but not limited to): utilization management, quality management, providerrelations, complaint & grievance procedures, care management, customer service, andclaims.Providers are encouraged to take the time to complete the survey. We welcome yourcomments and feedback on the services you have received from our staff and areinterested in how we can improve provider services. The results are reviewed bothinternally and with the Quality and Care Management Committee. The Committeeidentifies areas for improvement and interventions are developed to increasesatisfaction in those targeted areas.If you are dissatisfied with any aspect of Community Care's operations, we urge you toexpress your concern by calling the Community Care Provider Line (1-888-251-2224). Ifan issue cannot be resolved informally, you may lodge a formal complaint. You mayexpress your provider complaint orally or in writing. If the complaint cannot be resolvedimmediately, Community Care will send a resolution letter within 30 days.Community Care also utilizes the formal Provider Advisory Committee to receivefeedback from Providers. The Committee meets quarterly and Providers areencouraged to participate. If you are interested in becoming involved in this committeeplease call the Provider Line at 1-888-251-2224 to get more details.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 86

III.K. Provider EducationCommunity Care offers provider training on a variety of topics, with a focus ondeveloping skills in managing care, meeting and exceeding performance standards, andensuring cultural competence in delivery of behavioral healthcare services throughoutthe network. The person who will receive mailings about these sessions is thedesignated contact person identified in your network application. Please check with yourCommunity Care provider relations representative for the name of this person or if youneed to change the contact person (key contact).III.L. Provider Advisory CommitteeAll Community Care providers are eligible, welcome, and urged to participate in theCommunity Care Provider Advisory Committee in their local area. These committeesare designed to allow providers to give feedback to Community Care on a regular basis.There are other Community Care committees that include providers. If you would like toparticipate, please call the Community Care Provider Line (1-888-251-2224).IV. Providing Services to HealthChoices Network MembersCommunity Care has developed specific procedures for providers to follow in providingbehavioral health services to HealthChoices members. These procedures: Verify that the services are covered. Ensure that every member receives the level of care that he/she requires. Provide member services in a seamless fashion. Ensure that care meets quality standards.The following sections detail procedures for providing services. As a part of CommunityCare's commitment to quality improvement, these procedures are updated as needed.A. Verifying Member Eligibility for HealthChoices Network ServicesB. Medical Necessity (Level of Care) CriteriaC. Obtaining Authorizations (Registration, Precertification)D. Standards for Member Access to Services (Appointments)E. Coordination of Care, Referrals, Transition of Care to Other ProvidersF. Care Management ServicesIn addition, Community Care has a policy to review proposed new treatments forbehavioral health disorders. To submit a new technology request for review, talk with aCommunity Care care manager. The care manager will forward your request toCommunity Care's Chief Medical Officer for review.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 87

For any questions about providing services to Community Care members, pleasecall the Provider Line at 1-888-251-2224 (24 hours a day/seven days a week).IV.A. Verifying Member Eligibility for HealthChoices Network ServicesCommunity Care strongly recommends that all providers verify with the member his/ herenrollment in HealthChoices. You can verify that an individual is eligible to receiveservices by calling the Provider Line at 1-888-251-2224. Due to the HealthChoicesBehavioral Health Expedited Enrollment initiative, it is critical that all providers checkEVS on any day in which services are being rendered.IV.B. Medical Necessity (Level of Care) CriteriaOn a member's initial visit you will evaluate the member and determine what behavioralhealth services you believe the member needs. However, before you provide theseservices, you must make sure the services meet Medical Necessity (Level of Care)Criteria in the applicable guideline.Community Care’s Care Management Department uses these criteria in determiningwhether to issue an authorization (preapproval, precertification) for service (See SectionIV.C).If the member’s clinical condition necessitates a level of care that is covered in theindividual’s benefit plan but that level of care is not available, the next highest coveredbenefit level of care will be authorized.Mental health Medical Necessity Criteria (Appendix T) may be obtained from:http://www.ccbh.com/providers/phealthchoices/medicalnecessityChemical dependency Medical Necessity Criteria, Pennsylvania Client PlacementCriteria (PCPC) may be obtained from: Department of Health, Bureau of Drug andAlcohol Programs, Room 929, Health and Welfare Building, Harrisburg, PA 17108 orfrom: http://www.ccbh.com/providers/phealthchoices/medicalnecessityAmerican Society for Addiction Medicine (ASAM) criteria may be obtained from:http://www.asam.org Patient Placement Criteria (PPC-2R) may also be obtained from:ASAM Publications Distribution Center 1-800-844-8948 or P.O. Box 101, AnnapolisJunction, MD 20701-0101.Some supplemental levels of care are not addressed in Appendix T. Community Carehas developed supplemental Medical Necessity Criteria for these levels of care. For acomplete list of these criteria, please visit Community Care’s website at:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 88

http://www.ccbh.com/providers/phealthchoices/medicalnecessityIV.C. Obtaining Approval to Provider Services (Outpatient Registration,Precertification, Authorization)Even though you have determined that the services you intend to provide meet MedicalNecessity (Level of Care) Criteria, you cannot be paid for any service unlessCommunity Care has agreed with the determination and has given you approval toprovide the service. Approval is an agreement between you and Community Care thatthe care you plan to provide to a specific member meets the applicable MedicalNecessity Criteria.Depending on the services you plan to provide to a member, you need to:Register outpatient services with Community Care.Obtain precertification (preapproval) for services.Obtain authorization.The Guidelines for Obtaining Approval for In-plan Services at the front of this ProviderManual list whether authorization, outpatient registration, or precertification is requiredto receive approval to perform the service. The forms and steps for registration orprecertification are listed below.You may also reference the fee schedule attached to your contract for bothapproval and billing rules.For Coordination of Benefits (COB) when Community Care is the secondary payer,Community Care must be notified telephonically upon a member’s admission to any ofthe following levels of care: (i) Inpatient Mental Health; (ii) Acute Partial Mental Health(iii) Medically Managed and Medically Monitored Inpatient Detoxification (4A & 3A); (iv)Medically Monitored Short Term and Long Term Residential Rehabilitation (3B & 3C); or(v) Halfway House. Providers must also complete and fax the Coordination of BenefitsPrimary Insurance Discharge Notification Form to Community Care within five businessdays of the member’s discharge date in order to avoid any reimbursement problems.PLEASE NOTE: Receiving authorization is not a promise that the claim will bepaid (other criteria must be met). Refer to the Billing Section of this ProviderManual.IV.C.1 Outpatient Registration ProcedureCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 89

If you, as a Community Care provider, are contracted to perform outpatient mentalhealth services for members, you may be authorized to perform a specific service for aspecific member by registering with Community Care, as described below.Outpatient Registration is intended to assist providers by:Decreasing administrative work.Reducing overhead costs.Improving availability and access to outpatient services.Eliminating service delays caused by waiting for authorization of outpatient services.Encouraging providers to manage outpatient treatment services.Eliminating the need for continued stay treatment plans.Easing billing process.Enhancing the quality of service delivered to members.Allowing clinicians to focus on service delivery.The Outpatient Registration (OPR) Form is used to register members for initialoutpatient services. Forms can be ordered by calling the Provider Line at 1-888-251-2224 or contacting your assigned provider representative. OPR Forms are availableonly to contracted providers registered with the state as:PsychiatristsPsychologistsFQHCOutpatient Drug and AlcoholOutpatient Mental HealthOther - Outpatient onlySee APPENDIX D for Performance Outcomes Management System (POMS)information.IV.C.2 Precertification/Preapproval Authorization Procedures *Providers must obtain precertification/preapproval before providing the followingservices to members:Mental Health ServicesAcute Partial HospitalizationBehavioral Health Rehabilitative Services (BHRS)Community Treatment Teams (CTT)/ Adult Assertive Community Treatment (ACT)Diversion and Acute Stabilization/RespiteElectroconvulsive TherapyFamily Based Mental Health Services (FBMHS)Family-Focused Solution BasedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 90

Family Functional TherapyIndividualized Residential Treatment/CRRInpatient HospitalizationMobile Mental Health Therapy (MMHT)Multisystemic Therapy (MST)Multidimensional Treatment Foster Care (MTFC)Psychiatric RehabilitationPsychiatric Rehabilitation ClubhousePsychological/ Neuropsychological TestingResidential Treatment Facilities (RTF)School-Based Partial Hospitalization ProgramSummer Therapeutic Activities ProgramChemical Dependency ServicesHalfway House 2BAcute Partial Hospitalization ProgramPartial (sleepover) Hospitalization ProgramMedically Managed Rehabilitation (hospital-based) 4BMedically Monitored Rehabilitation (short-term, non-hospital) 3BMedically Monitored Rehabilitation (long-term, non-hospital) 3CMedically Managed Detoxification (hospital-based) 4AMedically Monitored Detoxification (non-hospital) 3ATo obtain precertification/preapproval authorization for these services for a member, callthe Community Care Provider Line 1-888-251-2224 24 hours a day/seven days a weekto review Medical Necessity Criteria with a care manager. If approved, an authorizationnumber will be generated for a certain time frame and number of units of service. Whenrequesting inpatient care, the Community Care precertification team staff will takeclinical information from behavioral health professionals. The provider will be given a“good faith authorization” if it appears the member will meet Medical Necessity Criteriafor an admission, with the number of days to be authorized. If it appears that MedicalNecessity Criteria are not met, the behavioral health professional will be informed of thisissue.The actual authorization will not be provided until the member has arrived at theaccepting hospital or facility and a physician has accepted the member for admission,unless the member is being transported by ambulance. If Medical Necessity Criteria arenot met, a Community Care professional advisor will be consulted.Precertification information can be provided by behavioral health professionals only.Other social services staff such as CYF, foster care, and school personnel will beadvised to take the member to an admitting facility, a nearby Emergency Department, ora crisis service for evaluation.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 91

When the precertification is for services that you deliver, the authorization number willbe given at the time of precertification/preapproval; also, an authorization report will alsobe made available.PLEASE NOTE: For certain services requiring precertification (see below), Thereare required documents that must be submitted before an authorization is given.The specific process and documentation requirements will be explained by thecare manager during the precertification call and/or via a scheduled providertraining session. Providers may also visit Community Care’s website as anadditional provider resource.Behavioral Health Rehabilitative Services (BHRS) – packet submission requiredFamily-Based Programs- packet submission requiredFamily-Focused Solution Based - packet submission requiredMultisystemic Therapy (MST) - packet submission requiredMultidimensional Treatment Foster Care (MTFC) packet submission requiredIndividualized Residential Treatment/CRR- packet submission requiredPsychological/Neuropsychological Testing – testing request form requiredResidential Treatment Facilities (RTF) - packet submission requiredSchool-Based Partial Hospitalization Program packet submission required*There may be contract specific differences for some levels of care. Contact your provider representativeor care management team for contract detail.IV.D. Standards for Member Access to Services (Appointments)Community Care standards require that members be given access to covered servicesin a timely manner, depending on the urgency of the need for services, as follows:Behavioral health life-threatening emergenciesBehavioral health non-life-threatening emergenciesUrgent behavioral health conditionsRoutine outpatient servicesCommunity Care monitors access data on a quarterly basis.IV.D.1 Behavioral Health EmergenciesCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 92

A behavioral health emergency is the sudden onset of a behavioral health conditionmanifesting itself by acute symptoms of sufficient severity that the absence ofimmediate medical or clinical attention could result in seriously jeopardizing orendangering the mental health or physical well-being of the member or seriouslyjeopardizing or endangering the physical well-being of a third party. Behavioral healthemergencies are of two types:A life-threatening behavioral health emergency is a behavioral health conditionthat results from a mental illness or substance use disorder. There is reason tobelieve the member is, or may become, homicidal or suicidal or the member ormember’s victim may suffer a disabling or permanent physical injury as a result ofthe member’s behavior or condition. The assessment that a life-threateningemergency exists is based upon statements or behavior, member self report, orinformation obtained subjectively or objectively and clinical judgment.Care is required immediately for life-threatening emergencies.A non-life-threatening behavioral health emergency is a behavioral health conditionthat results from a mental illness or substance use disorder from which the membermay suffer significant physical or emotional deterioration resulting in hospitalizationor partial hospitalization unless an intervention is made within one hour.Care is required within one hour for non-life-threatening emergencies.Emergency services do not need precertification (preapproval) by Community Care.Community Care expects that the emergency room, mobile crisis service, or outpatientprovider will take immediate action for the safety of the member and others and willregister with Community Care for outpatient services as soon as the situation isstabilized.If Community Care is contacted regarding a member’s need for an emergency service,Community Care will provide a referral to an emergency provider, help arrangeemergency transportation through the member's physical health managed careorganization (PHMCO) and ensure that emergency services are made availableimmediately or within one hour of the contact. The customer service representative mayfollow up with the provider to ascertain compliance with this standard for access toservices.IV.D.2 Urgent Behavioral Health ConditionsUrgent behavioral health conditions of either of the following constitute an urgentsituation:As a result of a mental illness or substance use disorder, a member is experiencingsigns, symptoms, or impairment in functioning that would likely require an intensivelevel of care within 24 hours if treatment is not providedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 93

ORA member expresses a readiness for, or amenability to, treatment if initiated within a24-hour period,Access to care for urgent behavioral health conditions must be provided within24 hours.IV.D.3 Routine Outpatient ServicesA routine outpatient service exists if the member exhibits signs or symptoms of a mentalillness or substance use disorder that indicate the need for assessment and/ortreatment without evidence of imminent or impending risk to the member or others or ofan acute, significant change in level of functioning.Access to routine services must be provided within seven days.The member may directly schedule an appointment with the provider, who will useMedical Necessity Criteria to determine the level of service that is needed and willcomplete registration with Community Care within 72 hours (with a grace period up to30 days) of the initial outpatient visit or request precertification, depending on theproposed treatment plan.If the member contacts Community Care directly, a care manager or customer servicerepresentative will help the member find an available appointment in the required timeframe.If the member prefers an alternative appointment time that falls beyond the prescribedtimeframe, the provider should document this in the provider’s appointment records.As part of Community Care's outreach efforts, we may contact a provider or a memberto ensure that certain appointments, such as ambulatory follow up appointments afterinpatient care, are kept.IV.E. Coordination of Care, Referrals, Transition of Care to Other ProvidersA member can only receive safe, comprehensive health care when all providers ofservices communicate and work together to educate and encourage the member tocomply with treatments and participate in available prevention programs. For a samplecoordination of care template and sample release of information forms, please seeAppendix B.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 94

IV.E.1 Community Care’s Expectations for Exchange of Information with PrimaryCare Physicians and within the Behavioral Health Continuum to FacilitateContinuity and Coordination of CareCoordination of Care with the member's primary care physician (PCP) or otherbehavioral health provider is always expected and particularly important when themember is prescribed a medication or treatment that may have an impact on themember's health or interact with medication or treatment prescribed by the PCP orpsychiatrist.Members for whom coordination of care is indicated include (but are not limited to):Those with chronic or serious medical illness.Those with a newly prescribed a psychotropic medication and who have been takingmedication for a medical condition.Those requiring multiple medications to treat serious and persistent mental illness.Those receiving medication with a history of medication compliance problems.Pregnant women who require medication to manage a behavioral health condition.Those with a substance abuse problem prescribed medication for a physical orbehavioral health problem, especially when the medication may be habituating.To promote needed communication with the PCP or other behavioral health provider,Community Care requires that you, the provider, tell each member about the importanceof involving his or her PCP or other behavioral health provider. Community Care alsoexpects that you will follow up with the PCP or other behavioral health provider. Youmust obtain the member’s written authorization to initiate communication. Providers arealso expected to take a holistic approach to promote the importance of the integration ofthe PHMCO services as a part of the member’s comprehensive recovery plan whenapplicable.Exchange of Information with the PCP, PHMCO, and other behavioral health specialistsis monitored on a routine basis from record review data. Results are made available toproviders via the Provider Line or Community Care’s website.IV.E.2 Referrals for Other Behavioral Health ServicesWhen you determine that a member requires behavioral health services that are notwithin the scope of your practice, call the Provider Line (1-888-251-2224) and ask acare manager for help in identifying Community Care contracted providers who canprovide those services.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 95

IV.E.3 Transition of Care to another Community Care ProviderWhen a Community Care provider contract is terminated, Community Care may allowup to a 60 day transition of care period or through the acute phase of the disorder,whichever is less, for members under the terminated provider's care.IV.F. Care Management ServicesShould a member require other than routine outpatient services, he/she will be assignedto a care manager. The goals of Community Care’s care management program are to:Ensure members’ timely access to geographically convenient needed services.Ensure quality care at the least-restrictive, most cost-effective level.Ensure equitable access to care for members across the network, in the mostappropriate clinical setting and at the appropriate level of care.Ensure that care meets standards and quality criteria.Assess and correct for over utilization, under utilization, inefficiency, and delays inaccess to services.Ensure that services are culturally competent.Ensure that the member and family (if indicated) are involved in treatment planning.Ensure that behavioral health services result in positive outcomes for members.For routine outpatient services, the Community Care customer service representativewill ensure members’ timely access to geographically convenient services.Care Managers may not deny care. If a member’s behavioral health status does notmeet Medical Necessity Criteria for the level of care or the services do not meet ClinicalPractice Guidelines criteria, the service is reviewed by a Community Care professionaladvisor (peer reviewers).IV.F.2 Peer ReviewersCommunity Care contracts with board-certified psychiatrists and addiction specialists,some with subspecialty expertise in providing child and adolescent or geriatric care andwith state-licensed psychologists to serve as peer reviewers. Peer reviewers arethoroughly trained to evaluate whether proposed services meet quality criteria, MedicalNecessity Criteria, and Clinical Practice Guidelines criteria. Community Care peerreviewers perform the following services: Render objective decisions on the level of care (Medical Necessity) and theappropriateness and quality of care. Advise Community Care’s Chief Medical Officer and Quality Management and CareManagement Departments. Consult with providers on precertification and concurrent and post-service reviews.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 96

Billing Manual forCommunity Care NetworkProvidersOriginal Claims Mailing Address:Community Care Behavioral Health OrganizationP.O. Box 2972Pittsburgh, PA 15230Corrected Claims Mailing Address:Community Care Behavioral Health OrganizationAttention: Claim CorrectionsOne Chatham Center, Suite 700112 Washington PlacePittsburgh, Pennsylvania 15219Provider Line: 1-888-251-CCBH (2224)Website: www.ccbh.comCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 97

Billing ManualCommunity Care Behavioral Health Organization (Community Care) has designed aclaims payment process that ensures prompt and accurate payment for services. In thishandbook you will find requirements and explanations for each component of the billingprocess.Prompt and accurate claims payment is one of the most important tasks of anymanaged care company and Community Care is committed to excelling in this area.Community Care’s ability to pay claims is directly related to the manner in which theprovider bills for services. If claim forms are incomplete or incorrect, claims for servicesthat should be reimbursed may be denied. Providers should pay careful attention to theprocesses used for capturing services and billing since a healthy cash flow is critical toany organization’s ability to provide service.This billing manual is prepared as a guide to policies and procedures for individualpractitioners, group practices, programs, facilities, and hospitals to reference whenbilling Community Care for HealthChoices members.Community Care endeavors to make billing and claims payment as straightforward aprocess for providers as possible. Community Care’s Provider ReimbursementDepartment is available for questions by calling 1-888-251-2224 and following theprompts to Provider Reimbursement. The Provider Reimbursement line is staffed from8:30 a.m.-12 p.m., and from 1- 5:00 p.m., Monday-Friday. If you call between 12 and 1p.m., you will receive a message advising you that the Provider Reimbursement line isclosed. You can check the status of your claim on Provider Online or call the ProviderReimbursement line back during the hours of operation. Questions related to claimsMUST be directed to the Community Care Provider Reimbursement Department.The essentials of completing claim forms are related to ensuring that all of the blocks onthe specific claim form are populated based on the instructions provided in this manual.It is important to note that for the HealthChoices program, these instructions are basedon Medical Assistance requirements rather than on the usual standards for billingcommercial and other insurance payors.Before Providing CareChecking EligibilityCommunity Care manages the behavioral health care benefits for HealthChoicesmembers in your area. Members must be Medicaid eligible to enroll with HealthChoices.Members are instructed to carry their Medicaid Access Card for eligibility verification.As a provider, it is important to ensure that a client is a current HealthChoices memberbefore providing services. No matter what authorization you receive, if the memberCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 98

to whom you provide services is not eligible for Medical Assistance on the dateservices are rendered, we will not be able to pay you.You can verify eligibility in a number of ways. You must use your 13-digit PROMISeProvider Identification Number. You can check eligibility directly by calling 1-800-766-5387. Swipe the member’s Access Card.Listed below is the website related to obtaining the EVS software:EVS software – approved commercial vendors of EVS software appear on the OMAPwebsite athttp://www.dpw.state.pa.us/provider/doingbusinesswithdpw/softwareandservicevendors/eligibilityverificationinformation/index.htmPlease remember that EVS is utilized to determine if a member is eligible and cannotbe utilized as the main source for TPL information or confirmation.Obtaining AuthorizationsAn authorization is an agreement that the care you want to provide to a specificmember meets medical necessity for that level of care. It is not a promise to pay aclaim.While most services require an authorization or registration notification for claimspayment, not all services require pre-approval or precertification. (Refer to theGuidelines for Obtaining Approval for In-Plan and Supplemental Services).The care management clinical staff is available 24 hours a day/seven days a week toprovide precertification or pre-approval for urgent services. For non-urgent services,care managers are available Monday through Friday during the hours of 8:30 a.m. to5:00 p.m. The Care Management Department is available at any time by calling 1-888-251- 2224 and selecting the appropriate options from the menu. Community Care’safter-hours coverage ensures providers will always have access to clinical personnel forclinically urgent situations.While an authorization number is generated at the time of approval, this number is notrequired to appear on the billing form for consideration of payment. Our informationsystem can match your bill to the appropriate authorization when you follow theprocedures outlined in the section of this manual entitled “Completing & SubmittingClaim Forms”.An authorization is NOT a guarantee of payment. All of the billing aspects of the servicemust be correct for the claim to be paid including meeting the timely file submissionguidelines.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 99

Even though an authorization may be issued to provide services, we cannot pay claimsfor a member who is not eligible for coverage by Medical Assistance at the timeservices were rendered. Since eligibility or enrollment status may change at any time,we strongly recommend that the member’s eligibility status be confirmed or verified atthe time of each visit. Failure to verify eligibility may result in claims denial.BillingProvider claims should be submitted on one of the two standard claim forms that areaccepted by Community Care– the UB-04 (Inpatient Services) or the CMS-1500(Outpatient Services). In addition, Community Care accepts claims that are submittedelectronically via a claims clearinghouse and through Community Care’s web basedapplication, Provider Online. As part of the Health Information Privacy andAccountability Act (HIPAA), Providers are required to use the standards set by the Act,837I (Inpatient Services) and 837P (Outpatient Services). Providers are stronglyencouraged to submit claims to Community Care electronically. For those providers whodo not bill electronically, original red-lined claim forms are required.Non-Par Contracted Providers:Please refer to your non-par contract for the appropriate procedure/modifier codes andfollow the claim submission requirements outlined in this Billing Section. Non-parclaims can be submitted electronically. Please contact the Provider ReimbursementDepartment to discuss requirements.Claims FilingClaims are to be submitted as soon as possible, once the applicable authorizationshave been obtained and services have been rendered.If you are having difficulties obtaining the authorization, submit your claim to ensurethat you are within the timely file deadline. It is easier and much faster to submit aclaim correction on the denial for “no authorization” than it is to file for an “exceptionto timely file.” Submitting without your authorization should be an exception andNOT a routine occurrence.Timely Filing Guidelines by ContractBoth initial billing and days to complete corrected claims are based on days from Dateof Service. The initial claim must be filed timely before ‘days to complete claimprocesses are applicable’.Allegheny – 90 days, 180 days to complete claim processBerks – 60 days, 120 days to complete claim processBlair – 90 days, 180 days to complete claim processCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 100

Carbon/Monroe/Pike – 90 days, 180 days to complete claim processChester – 60 days, 180 days to complete claim processErie - 90 days, 180 days to complete the claim processLycoming/Clinton - 90 days, 180 days to complete the claim processNorth Central – 90 days, 180 days to complete claim process (North Central includesBradford, Cameron, Centre, Clarion, Clearfield, Columbia, Elk, Forest, Huntingdon,Jefferson, Juniata, McKean, Mifflin, Montour, Northumberland, Potter, Schuylkill,Snyder, Sullivan, Tioga, Union, Warren, and Wayne counties)Northeast – 90 days, 180 days to complete claim process (Northeast includesLackawanna, Luzerne, Susquehanna, and Wyoming counties)York/Adams – 90 days, 180 days to complete claim processCoordination of Benefits-COB Timely FileSecondary claims received outside of timely file guidelines of the respectiveHealthChoices contracts must be received within 30 days from the processed date ofthe primary insurance remittance advice.The above applies to all contracted counties.Timely File Submission RequirementsRequests for an exception to the timely file guidelines must include documentationexplaining why the exception is warranted.The following items must be included with your appeal request:Providers must forward a letter outlining the details related to the reason(s) a timelyfile appeal is being requested on organization letterhead.A copy of the original billed claim (CMS-1500 or UB-04).The claim submitted must be CORRECT, meaning all required fields are populatedaccording to this billing manual.The form number must be at the top of each claim form.The authorization must be in place.The member must be eligible for the date(s) of service billed.If the claim was billed electronically, a copy of the electronic confirmation ’997’ reportis required to be included with the appeal documents.Providers must show proof of follow-up every 45 days. Failure to complete timely filefollow-up is not an acceptable reason for requesting a timely file exception.Claims must be on file prior to requesting a Timely File appeal.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 101

Timely File requests are to be mailed to the address listed below:Community Care Behavioral Health OrganizationProvider Reimbursement Department – Timely File112 Washington PlaceOne Chatham Center, Suite 700Pittsburgh, PA 15219Attention: Place the Name of the Respective Project CoordinatorCommunity Care will present the timely file appeal requests to the applicable oversightgroup for approval.Submitting Primary Claim FormsDepending on the type of service that you are providing, you must bill Community Carethrough Electronic Data Interchange (EDI), via a claims clearinghouse, throughCommunity Care’s web-based application, Provider Online, or on paper utilizing theapplicable claim form (UB-04 or CMS-1500).Providers of inpatient services and accredited RTFs will submit claims via one of thefollowing methods:EDI claims-837 Institutional fileProvider Online-UB screensPaper Claims-UB-04Individual practitioners or other providers providing outpatient services (ambulatory,non-hospital residential, and non-accredited RTF) will submit claims via one of thefollowing methods:EDI claims-837 Professional fileProvider Online-HFCA screensPaper Claims-CMS-1500Providers should mail original paper claims to:Community Care Behavioral Health OrganizationP.O. Box 2972Pittsburgh, PA 15230EDI Claims Processing InformationClaims Clearinghouse Submissions:Payor Name – Community Care BHOPayor ID - # 23282Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 102

Providers have two options to submit claims electronically. The first of which is forclaims to be submitted via a claims clearinghouse. Providers using this method mustexecute a contract with one of the clearinghouses listed below. The clearinghouseslisted below are those with which we currently have working relationships. Beyond thesethree clearinghouses, we are certainly willing to work with any other clearinghouse thatmay express interest in doing so.Relay Health (McKesson)EMDEON (WebMD)Xactimed/MedAssetsEDI (Claims Clearinghouse) RequirementsThe EDI process for submitting claims to Community Care is the same as whensubmitting claims to other insurance carriers via EDI. The EDI specific fields will varydepending on the EDI software with which your billing system operates. However, therequired fields for EDI claims submissions to Community Care through a claimsclearinghouse are: Community Care’s Payor ID “23282” NPI number Member’s Medicaid identification number Payer’s name “Community Care BHO” Member demographics Provider demographics Claim detailCommunity Care’s Web Based Application, Provider OnlineThe second method for claims to be submitted electronically is the utilization ofCommunity Care’s web based application, Provider Online. Providers are required tocomplete a non-disclosure agreement prior to receiving any access to the ProviderOnline website. Providers must use Microsoft Internet Explorer 6.1 or greater whenutilizing the Provider Online website.For further instructions visit: http://www.ccbh.com/Providers/SecureSites/Claims.phpProvider Online enables providers to:Check the status of a claim online.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 103

Provide an alternative to the use of a claims clearinghouse in the submission of an837 claim file electronically. Provide a vehicle for providers to key claims directly into the system via an Onlinebatch. Review authorizations. Submit claim corrections.Internet access is required to use Provider Online. Providers can query the claimssystem in real time and/or review authorizations, increasing the speed at which vitalinformation can be obtained. A provider can use Provider Online to query claims statusand not choose to submit claims through the application.The status of any claims submitted to Community Care can be queried viaProvider Online, regardless of the manner in which it was submitted.Providers considering using Provider Online for direct submission of their 837 files mustsubmit two 837-test files; both files must pass the testing phase before the provider willbe given access to submit their 837 files via Provider Online into our productionenvironment. Upon requesting a non-disclosure form for this access, Community Carewill provide documentation on our 837 requirements and complete directions on ourtesting process.Electronic files can be submitted any time of day or night 24 hours a day/7 days a weekfrom your clearinghouse or via Provider Online.The daily process runs five days a week Monday through Friday, 7 a.m. – midnight.Monitors will not process any claims from midnight until 7 a.m., Monday through Friday.The monitors will process on Saturdays between 7 and 11:30 a.m. and on Sundaysfrom 9 a.m. to 6:30 p.m. All output will be available prior to the respective cutoff times orafter 7 a.m., Monday through Friday.Below is a listing of Community Care upfront rejection for EDI claim submissions, at theclaim level: Billing NPI either missing or invalid (less than 9 characters) - Detail reject errorcode/description = MCN0001/Missing or Invalid Billing NPI Missing Principal Diagnosis Code - Detail reject error code/description =MCN0002/Diagnosis Required More than 99 detail lines - Detail reject error code/description = MCN0003/Max 99Service Line ExceededMissing Diagnosis Pointer - Detail reject error code/description = MCN0004/MissingDiagnosis Pointer Missing Quantity Professional Claim - Detail reject error code/description =MCN0005/Invalid Quantity Professional ClaimCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 104

Missing Quantity Institutional Claim - Detail reject error code/description =MCN0006/Invalid Quantity Institutional Claim Missing Procedure Code – Detail reject error code/description = MCN0007/MissingProcedure Code Missing Subscriber Last Name - Detail reject error code/description =CN0008/Missing Subscriber Last Name Invalid Charge Amount - Detail reject error code/description = MCN0009/InvalidCharge Amount Missing Subscriber ID # - Detail reject error code/description = MCN0010/MissingSubscriber ID # Missing Place of Service - Detail reject error code/description = MCN0011/Place ofService Missing Invalid Diagnosis Code – Detail error code/description = CLM0314/Non ValidDiagnosis, or missing a required Diagnosis CodeGeneral Claims Submission RulesAll claim forms must contain: Member ID number (10 digit MA Recipient ID.) NPI number. ICD-9 diagnosis codes: Behavioral Health Diagnosis Range 290-319 billed to the 5 th digit, if applicable.Do Not Add Zero’s. Diagnosis code 799.9 is not an appropriate or acceptable diagnosis unless thediagnosis code is billed with an acceptable procedure code. Please refer toProvider Alert #10 8-18-2009-Appropriate Use of Diagnosis Code 799.9, locatedonline at www.ccbh.com in PDF format. Procedure codes which appear on the Community Care Fee Schedule. “Billing Units” as defined on the Community Care Fee Schedule. The date span (to-from) should be equal to the total number of units billed for theroom and board revenue codes. Data must be within the lines of the applicable claim form box. Font should be Arial and the size should be between 10 and 12. Acceptable paper claim forms include the UB04 for institutional claims and theCMS1500 for professional claims.Paper claims must be completed as outlined in this manual or the claims cannot bescanned into the claims processing system. It is preferred that paper claims besubmitted on the standard red and white forms, as black grid lines (copied forms) willinterfere with the scanning process. Claims that are not completed correctly may bedenied. The Explanation of Payment (EOP) for the claim in question will include a denialcode that indicates why the claim could not be paid.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 105

Required Claim FieldsIn the following pages of detailed instructions:• The “block number” refers to the space on the relevant claim form.• The “required/optional/not required” column indicates the blocks that must becompleted (marked with an R for required), can be completed but are not required(marked with an N for not-required), or should be included but are not required(marked as optional).Note: Any claim field marked “REQUIRED” must be populated on the claim formor payment will be denied.CMS-1500Listed below are instructions for completing the specific fields on the CMS-1500 forCommunity Care.BLOCK # Field NameREQUIRED orNOT REQUIRED1 Payor Identifier Not required1a Member Number = 10 Digit Medicaid Recipient RequiredID2 Member’s NameRequired(last name, first name, middle initial)3 Member’s Date of Birth (MM/DD/YY) Required3 Sex Not Required4 Insured’s NameRequired for COB(last name, first name, middle initial)5 Member’s Address Required6 Member’s Relationship to InsuredRequired(Always check box for self)7 Member’s AddressRequired for COB(number, apartment number, street, city, zip code,telephone number with area code)8 Member’s StatusRequired for COB(check boxes for single, married, other, employed,full-time student, part-time student)9 Other Insured’s NameRequired for COB(last name, first name, middle initial)9a Other Insured’s Policy or Group Required for COB9b Other Insured’s Date of Birth (MM/DD/YY) and Sex Required for COB9c Employer’s Name or School Name Required for COB9d Insurance Plan Name or Program Name Required for COB10a-c Member’s Condition Related to Employment, autoaccident, and other accidentNot requiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 106

11 Insured policy, Group or FECA Number (ifNot requiredapplicable)11a Insured’s Date of Birth and Sex Not required11b Employer’s Name or School Not required11c Insurance Plan Name or Program Name (if Not requiredapplicable)11d Is there another health benefit plan?(Check block Yes or No)RequiredIf Yes, return to and12 Member’s or Authorized Person’s SignatureAll invoices must have either the Recipient’ssignature or the words “Signature Exceptions”or “Signatures on File” and the datecomplete item 9a-dRequired13 Insured or Authorized Person’s Signature Not required14 Date of Current Illness Not required15 Date of Same or Similar Illness Not required16 Date Client Unable to Work in Current Occupation Not required17 Name of Referring Physician or Other Source (if Not requiredapplicable)17a Name of Referring Physician or Other Source Not required17b Referring Physician’s ID Not required18 Hospitalization Dates Related to CurrentServicesFROMRequired18 Hospitalization Dates Related to CurrentServicesTORequired19 Reserved for Local Use Not required20 Outside Lab Not requiredOutside Lab ChargesNot required21 Diagnosis Code ICD-9-CM BH Diagnosis Range Required290 – 319.21 Diagnosis Code 2 Not required21 Diagnosis Code 3 Not required21 Diagnosis Code 4 Not required22 Medicaid Resubmission Code/Original ReferralNumber required when submitting a correctedclaim.Required23 Prior Authorization Number Not required24A Date of ServiceRequiredFROM24A Date of ServiceRequiredTO24B Place of Service (See Community Care’s FeeSchedule)RequiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 107

24C EMG Not required24D Procedure CodeRequiredEnter the applicable procedure codes &modifiers from Community Care’s FeeSchedule24D Modifier Required24E Diagnosis Code PointerRequiredEnter the diagnosis reference number asshown in block 21 to correlate the diagnosiscode to the procedure or service performed24F Total Charges being billed for the line Required24G Total Days/ Units billed for the lineRequired(two digit maximum per line, 99) No decimalpoint.24H EPSDT Family Plan (if applicable) Not required24I ID Qual Not required24J Rendering Prov NPI# Required25 Federal Tax ID Number (Used for income tax Requiredpurposes). It MUST be associated with thevendor information on your contract withCommunity Care.26 Provider’s Patient Account Number Required27 Accept Assignment28 Total ChargesRequiredEnter the total sum of 24 F lines 1-6 in dollarsand cents. No decimal point.29 Amount Paid by Other Insurance (if applicable) Required for COBEnter total sum of 24 K lines 1-6 in dollars andcents30 Balance Due from Community Care Not required31 Name of physician, clinician, or facility named Requiredon the authorization for the service and thedate32 Name and Address of Facility where services were Not requiredrendered33 Provider’s Vendor Name, Address, Zip Code, Requiredand Telephone NumberEnter the name that should appear on yourchecks and the address where the checksshould be mailed. This information shouldmatch the vendor information on yourCommunity Care contract.33a NPI# Required33b Unlabeled Not requiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 108

UB-04Listed below are instructions for completing the specific fields on the UB-04 claim formfor Community Care.REQUIRED;OPTIONAL: orBLOCK # Field NameNOT REQUIRED1 Name of Provider Required2 Pay to Data Not required3a Patient Control Number Required3b Medical Record Number Not required4 Type of Bill Required5 Federal Tax ID Number (Is used for income tax Requiredpurposes.) It MUST be associated with thevendor information on your contract withCommunity Care.6 From Required6 Through Required7 Unlabeled Not required8a Patient Name ID Required8b First Name Required8b Last Name Required8b Patient Name Required9a Patient Address Required9b City Required9c State Required9d Zip Code Required9e Country Code Required10 Birthdate Required11 Sex Not required12 Admission Required forINPATIENT claimsONLY13 Admission Hour Required forINPATIENT claimsONLY14 Admission Type Required forINPATIENT claimsONLY15 Source of Admission Required forINPATIENT claimsONLY16 Discharge Hour Required forINPATIENT claimsONLYCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 109

17 Discharge Status Required forINPATIENT claimsONLY18 Cond. Code 1 Not required19 Cond. Code 2 Not required20 Cond. Code 3 Not required21 Cond. Code 4 Not required22 Cond. Code 5 Not required23 Cond. Code 6 Not required24 Cond. Code 7 Not required25 Cond. Code 8 Not required26 Cond. Code 9 Not required27 Cond. Code 10 Not required28 Cond. Code 11 Not required29 Accident State Not required30 Unlabeled Not required31a Occur. Code 1 Not required31a. Occur. Date 1 Not required31b Occur. Code 5 Not required31b Occur. Date 5 Not required32a Occur. Code 2 Not required32a Occur. Date 2 Not required33b Occur. Code 6 Not required33b Occur. Date 6 Not required33a Occur. Code 3 Not required33a Occur. Date 3 Not required33b Occur. Code 7 Not required33b Occur. Date 7 Not required34a Occur. Code 4 Not required34a Occur. Date 4 Not required34b Occur. Code 8 Not required34b Occur. Date 8 Not required35 Occur. Span Not required36 Occur. Span Not required37a Unlabeled Not required37b Unlabeled Not required38 Responsible Party Not required39 Value Amount Not required39 Value Code Not required40a Value Amount Not required40a Value Code Not required41a Value Amount Not required41a Value Code Not required42 Rev. Code Required – IfAuthorizedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 110

43 Description Not required44 HCPCS & Modifier / Rates/HIPPS Required – IfAuthorized45 Service Date RequiredNOTE – Not requiredif confinement claim(determined byreferencing Type ofBill info)46 Service Units Required47 Total Charges Required48 Non-Covered Charges Not required49 Unlabeled Not required50A Payor Name – Primary Required50B Payor Name – Secondary Required50C Payor Name – Tertiary Required51A Plan ID – Primary Required51B Plan ID - Secondary Required51C Plan ID - Tertiary Required52 Release Information Not required53 Assignment of Benefits Not required54 Prior Payments Not required55 Est. Amt. Due Not required56 NPI # Required57 Other Provider ID Not required58a Insured’s First Name Required58a Insured’s Last Name Required58a Insured’s Name Required58b Insured’s First Name Not required58b Insured’s Last Name Not required58b Insured’s Name Not required59a P. Rel. Not required60a Member’s Unique ID (13-Digit MedicaidRequiredRecipient ID for primary HealthChoices claims)60b Cert. SSN HIC ID No. Not required61 Group Name Not required62 Ins Group No. Not required63 Treatment Authorization Code Not required64 Doc Control Number- Required when submitting a Requiredcorrected claim.65 Employer Name Not required66 Diagnosis Version Qualifier Not required67 Principal Diagnosis Code ICD-9-CM BHDiagnosis Range 290 – 319.RequiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 111

67a-q Diag. Code Required68 Unlabeled Not required69 Adm. Diagnosis Code Required70 Patient Reason Diagnosis Code Required71 PPS Code Not required72 Ext Cause of Injury Not required73 Unlabeled Not required74 Prin. Procedure Code Not required74 Prin. Procedure Date Not required74a Other Procedure Code Not required74a Other Procedure Date Not required74b Other Procedure Code Not required74b Other Procedure Date Not required74c Other Procedure Code Not required74c Other Procedure Date Not required74d Other Procedure Code Not required74d Other Procedure Date Not required74e Other Procedure Code Not required74e Other Procedure Date Not required75 NPI # Not required76 Attending Phys. ID/Phys. Name Not required76 Qual. Not required77 Operating Not required78 Other Not required79 Other Not required80 Remarks Not required81 Code Not requiredThird Party Liability (TPL) -Coordination of Benefits (COB)In instances when a Community Care HealthChoices member has primary insurancecoverage, HealthChoices is always the payor of last resort. Community Care providersare required to verify primary insurance as well as bill the primary insurance beforebilling Community Care. If you fail to bill a HealthChoices member’s primary insurancecompany or third party payer first, your claim will be denied by Community Care.When you receive the Explanation of Payment (EOP) for claims that are deniedbecause Community Care’s records indicate the member in question is covered byanother payer. You may call the Community Care Provider Line, 1-888-251-2224 priorto submitting a claim to confirm a member’s other insurance coverage. Community Carewill provide you with details associated with the member’s other coverage.HealthChoices is the PAYOR OF LAST RESORT – All other applicable insuranceMUST be billed prior to submitting a claim to Community Care.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 112

The primary payor’s EOP/EOB must include the denial legend/key code.Neither a provider nor a HealthChoices member can elect to avoid the requirementsof the primary carrier.Providers who are not part of the primary carrier’s network should redirect themember in-network or seek an out-of-network arrangement with the primarycarrier.If the primary denied for medical necessity, the provider MUST follow the denialprocedures of the primary carrier and exhaust all Act 68 grievance levels to obtainpayment. If the denial is upheld, Community Care will conduct a retrospective clinicalreview prior to making an authorization determination.When paying secondary claims, Community Care considers the PatientLiability/Patient Responsibility (Co-insurance/Deductible) indicated on theprimary’s EOB and will pay up to the amount listed on the Community Care FeeScheduleProviders who are billing ACT62 claims must bill the member’s primary insurance,prior to billing Community Care unless:• The policy is self-funded.• There are fewer than 50 employees covered by the employer’s health plan.• The insurance plan is not issued in the Commonwealth of PA.• Tri-Care/Champus is exempt from Act 62.Providers who are interested in billing COB claims electronically must contact theProvider Reimbursement Department to review the COB electronic billingrequirements, as well as to coordinate a secondary EDI test file.Basic facts to make proper COB billing easier:Obtain insurance information from the member, for every applicable policy:• Carrier Name• Insured’s Name• Policy Number• Telephone NumberContact insurance carrier to verify benefits:• Confirm policy effective date• Confirm benefits• Confirm billing informationFollow the guidelines of the primary carrier:• Verify the provider, group and/or facility is contracted, in the primary network.• Obtain necessary authorizations• Render service• Bill service to primary carrierCommunity Care is always the payor of last resort:• You cannot elect to ignore the existence of another carrier.• Bill all other carriers before submitting to Community Care.• Primary denial must reflect an acceptable non-covered reason and not failure tofollow the primary carrier’s guidelines.Payment received from Primary Carrier:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 113

• Explanation of Benefits (EOB) indicates a Patient Liability• Bill all third party carriers that may precede Community Care.• Community Care is the last payor:o Applicable authorization MUST be obtained.o Submit claim to Community Care with a copy of the Primary Insurance EOB.o Community Care will pay the Patient Liability/Patient Responsibility (Co-Insurance/Deductible) up to the Community Care Fee Schedule amount.o Coordination of Benefits (COB) claims received outside of the initial timely fileguidelines must be received within 30 days from the date printed on theprimary explanation of benefits (EOB).Denials received from Primary Carrier which are NOT acceptable:• Primary Denial indicates insurance guidelines were NOT followed to obtainprimary coverage.o NOT REIMBURSABLE BY COMMUNITY CARE BEHAVIORAL HEALTH• Primary Denial indicates service not medically necessary.o NOT REIMBURSABLE BY COMMUNITY CARE BEHAVIORAL HEALTH• Primary Denial indicates no auth or precertification obtained.o NOT REIMBURSABLE BY COMMUNITY CARE BEHAVIORAL HEALTH• Providers are required to complete the following steps, if the Primary EOBindicates the service is denied, due to medical necessity:o Exhaust all appeal levels with the carrier.o If an appeal is granted by the carrier, submit the claim to Community Carewith the following information:- Copy of Original EOB.- Copy of 2 nd Level Appeal Decision.- Claim form, CMS-1500 or UB-04.Acceptable denials received from Primary Carrier:Service not covered by plan.Yearly benefit is exhausted.Lifetime benefit is exhausted.Applied to deductible.Applied to out-of-pocket.Pre-existing condition, service not covered.Coverage terminated.Acceptable documentation of primary denial:EOB stating non-covered reason, including denial reason code and description.Letter from carrier advising non-covered reason.If Medicare exhausted, include a copy of the HIQA screen with the claim submission.Screen print from primary carrier’s system showing non-covered status.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 114

Coordination of Benefits (COB) claims received outside of the initial timely fileguidelines must be received within 30 days from the date printed on the primaryexplanation of benefits (EOB).Secondary Electronic Claim Submission:Only secondary outpatient claims can be submitted electronically via an 837Professional file. Electronic files can be received either via a claims clearinghouse orsubmitted directly via Community Care’s Provider Online Website in an 837 professionalfile format only. If submitting secondary EDI files directly to Community Care providersare required to submit one small test file of 2-3 claims. Below are our secondary EDIrequirements:OIC PaidDeductibleCoinsCopayOIC adjustment reason codes - For reference:http://www.wpc-edi.com/content/view/698/1Professional ClaimsCommunity Care Behavioral Health requires the submission of all COB relevant data.The NM1 segment containing the name and ID of primary insurance companyThe SVD segment and all supporting CAS segments at the service level.The primary insurance allowed amount at the service level is very helpful, but notrequired.Understanding Claim CorrectionsIf you receive a payment that you believe is an underpayment or an overpayment youwill need to initiate a claim correction. Clarification of denials can be obtained by callingthe Provider Line, 1-888-251-2224, and following the prompts for ProviderReimbursement. Community Care strongly recommends that all claim corrections aresubmitted electronically (837I, 837P, or Prelog). Community care will accept a UB-04 ora CMS-1500 form with “Corrected Claim” and the form/claim number written on the top.You must indicate which components of the original claim form you are correcting bydrawing a line through or circling the error. Make sure the correction is clearly identified.Community Care cannot process a claim correction based on any Provider’sAccounts Receivable listing, Community Care remittance advice, or a ProviderOnline screen print.Claim Correction Requirements:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 115

Many of the services covered by Community Care can be rendered multiple times onthe same date of service. When the same service has been rendered multiple times(same procedure code and modifier), the total number of units rendered should becombined on one line on the claim form or you can submit as separate lines on thesame claim form by place of service. However, if a claim is submitted for a serviceand then subsequent units are discovered, the subsequent units MUST be submittedas a claim correction to the original submission (3 units originally billed, an additional4 units sent to provider’s billing office – a “corrected claim” for 7 units should besubmitted to Community Care).Anytime you receive a denial for a “duplicate claim,” verify that the service is a trueduplicate and not a claim submission for subsequent units on the same day ofservice.If there is an issue with your claim related to the modifier, a “corrected claim,”reflecting the correct procedure code and modifier must be submitted to update theoriginal claim.To correct any inadvertent error in billing, submit a “corrected claim” to update theoriginal claim.To reverse a denied claim, a “corrected claim” MUST be submitted with theadditional information to update the original claim.Providers who mail paper corrected claims are required to stamp or write the words“Corrected Claim” and the form/claim number on all corrected claims, regardless ofthe claim form type. This should NOT be done in red ink within the body of the claim.Red ink interferes with the scanning process. Black ink does not.Providers who mail paper corrected claim forms are required to populate Block 22 ofthe CMS-1500 or Block 64 of the UB-04 with the original claim/form number.All claim corrections are subject to the timely file guidelines.Community Care strongly recommends all claim corrections be completedelectronically.Submitting Claim CorrectionsCommunity Care can accept claim corrections via three methods:1. EDI – Preferred method2. Provider Online3. Paper Claim CorrectionsProvider Online – Claim CorrectionsCommunity Care strongly encourages providers to complete claim corrections viaProvider Online; Community Care’s web based product. Submitting claims correctionsto Community Care via Provider Online expedites the processing of and ensures theaccuracy of completing the claim correction process. The Provider Online User Guidecan be accessed via the website below. The Provider Online User Guide is locatedunder the Reference Library. To obtain access to Provider Online, please call theProvider Line 1-888-251-2224 and follow the prompts to the Provider ReimbursementDepartment.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 116

Provider Online Website:https://online.ccbh.com/ccbhproductionPaper Claim CMS-1500 – Claim CorrectionsProvider is required to write ‘Corrected Claim’ at the top of each CMS-1500 whensubmitting a corrected claim to Community Care. Draw a line through or circle theincorrect information and write the correct information directly on the CMS-1500.Include the original claim/form number on the CMS-1500 when submitting a claimcorrection.UB-04 - Claim Corrections Type of Bill (Form Locator 4)Provider is required to write ‘Corrected Claim’ at the top of each UB-04 whensubmitting a corrected claim to Community Care.Form Locator 4-Type of Bill must represent the appropriate three digit code. Pleaserefer to the information provided below. Draw a line through or circle the incorrectinformation and write the correct information directly on the UB-04.Include the original claim/form number on the UB-04 when submitting a claimcorrection.UB-04 - Claim Corrections - Type of Bill (Form Locator 4)Applicable to Provider Online, Claims Clearinghouses & Paper ClaimsThis three digit code gives three specific pieces of information. First Digit – identifies the type of facility Second Digit – classifies the type of care Third Digit – indicates the sequence of this bill in this particular episode of careFirst Digit 1 - Type of Facility – HospitalSecond Digit 1 - Bill Classification – InpatientThird Digit 1 - Admit through Discharge Claim 2 - Interim – First Claim 3 - Subsequent Interim Claims 4 - Last Interim Claim 7 - Replacement of a Prior Claim 8 – Claim VoidsMail Paper Claim Corrections To:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 117

Community Care Behavioral Health OrganizationAttn: Claims Corrections112 Washington PlaceOne Chatham Center, Suite 700Pittsburgh, PA 15219EDIPayor Name – Community Care BHOPayor ID - # 23282Community Care strongly urges providers who submit via a Clearinghouse confirmreceipt of their 997 report. Within three to five days after confirming receipt of the 997report, providers can review claim status via Provider Online.Unless Provider Online lists a check number and a check date, the claim has notbeen finalized. Please do not call the Provider Line to request payment or denialinformation unless a check number and check date is populated.Paper ClaimsMailing Address:Community Care Behavioral Health OrganizationP.O. Box 2972Pittsburgh, PA 15230Receipt of paper claim submissions can be verified 14 days after submission byaccessing Provider Online.Community Care strongly recommends providers use Provider Online to confirmpayment or denial status.Unless Provider Online lists a check number and a check date, the claim has not beenfinalized. Please do not call the Provider Line to request payment or denial informationunless a check number and check date is populated.Claim Buzz Words and PhrasesAct 62: Autism Insurance Law, PA Act 62 of 2008Adjudicate: When a claim is processed and the result is ‘posted/paid’, the claim hasadjudicated. It is the final step for that particular claim. If a corrected claim is presented,the corrected claim will have a new ‘posted/paid’ date.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 118

Authorization Rules: The definition and parameters of the service as listed on theCommunity Care Fee Schedule. (If the authorization rules have not been followed, theclaim will deny).COB: Coordination of BenefitsCommunity Care HealthChoices Member: A person receiving Medical Assistancethrough a county serviced by Community Care. The person who received treatment andwas named on the claim submitted to Community Care.Community Care Member Number: The Member’s 10-digit Recipient Number issuedby Medical Assistance.Community Care Provider: This is you, as a contracted private practitioner, agency,facility, or hospital.Consecutive Billing Days: A continuous run of days in which the same procedurecode was rendered to the same member by the same Community Care Behavioralprovider (does not have to be by the same clinician within your agency).Date of Service (DOS): The date the service was rendered.EDI: Electronic Data Interchange; the computer software system used to encode andtransmit claims data electronically.EFT: Electronic Fund TransferEVS: Eligibility Verification System - Used by providers to verify member’sHealthChoices or Medicaid eligibility.Federal Tax ID Number: The number used to identify your agency on your FederalIncome Tax returns.Form Number/Claim Number: The claim system generated eight digit number whichappears on the Community Care Remittance Advice and the Provider Online claimdetail screen. Providers are required to include this number when completing all claimcorrections.MA Provider ID Number: The 13-digit number assigned by the Commonwealth.Member Eligibility: Member is covered for behavioral health by Community Care onthe date of service. Eligibility can be verified through EVS by using a card swipemachine or calling 1-800-766-5387. If the Member is ineligible, your claim will deny,even if services were authorized.NPI Number: National Provider Identification Number (mandatory as of May 23, 2008).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 119

Community Care Procedure Code: The code assigned to a service and defined on theCommunity Care Service Code Fee Schedule.Community Care Modifier: A two character code attached to a procedure code toidentify a different service, to allow a unique rate, or to facilitate reporting.OPR: Outpatient Registration – Community Care’s method for notification by providersof members receiving ‘outpatient’ services.Provider Online: Community Care’s web based application for submitting claimsdirectly and for checking the status of claims.Vendor: This is the name and address which appears on the Community CareRemittance Advice. The Vendor is associated with a Federal Tax ID defined by theprovider. The Vendor information on the claim form must match the information on theprovider’s contract or the claims will deny.TPL: Third Party LiabilityUnit of Service: The ‘billing unit’ defined on the Community Care Fee Schedule.NOTE: Your ‘charge collection units’ may need to be converted to ‘billing units’.Usual Charge: The amount charged by your agency, to all payers, for the service beingrendered.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 120

Glossary of Terms and AbbreviationsThe following terms and abbreviations are defined as they are used in the CommunityCare Provider Manual for HealthChoices providers.Abuse: Provider practices that are inconsistent with sound fiscal, business, or medicalpractices and result in unnecessary cost to the Medicaid program or in reimbursementfor services that are not medically necessary or that fail to meet professionallyrecognized standards for health care. Also, recipient, i.e., Community Care member,practices that result in unnecessary cost to the Medicaid program.ALOS: Average Length of StayASAM: American Society for Addiction MedicineAuthorization: An agreement that the services planned for a specific member meet“Medical Necessity Criteria”/level of care criteria. A provider must receive authorizationto provide the services for a claim to be honored, but receiving authorization is not apromise that the claim will be paid (other criteria must be met).BDAP: Bureau of Drug and Alcohol ProgramsBHMCO: Behavioral Health Managed Care Organization, e.g., Community CareBehavioral Health Organization.BHRSCA: Behavioral Health Rehabilitation Services for Children and Adolescents(formerly referred to as EPSDT or “wraparound”)BPI: Bureau of Program Integrity (Commonwealth of Pennsylvania)CARF: Committee on Accreditation of Rehabilitation FacilitiesCASSP: Child and Adolescent Service System ProgramsCBCL: Child Behavior Check ListCMS: Center for Medicare and Medicaid Services (previously HCFA/Health CareFinancing Administration)COA: Council on AccreditationComplaint: An oral or written expression of dissatisfaction from a member or providerthat initiates a formal investigation process.CSP: Community Support ProgramCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 121

C/FST: Consumer/Family Satisfaction TeamDOH: Department of Health; the state agency responsible for licensing and inspectinghealthcare facilities and services and setting quality standards for providing care toHealthChoices (Medicaid, Medical Assistance) members.DOS: Date(s) of Service (most often used on claim forms and similar documents)DPW: Department of Public Welfare; the state agency that administers HealthChoicesand other Medicaid/Medical Assistance programs.EDI: Electronic Data Interchange; the computer software system used to encode andtransmit claims data electronically.Emergency: The sudden onset of a behavioral health condition manifesting itself byacute symptoms of sufficient severity, such that a prudent layperson who possesses anaverage knowledge of health and medicine could reasonably expect that the absence ofimmediate medical or clinical attention could result in seriously jeopardizing orendangering the mental health or physical well-being of the enrollee or seriouslyjeopardizing or endangering the physical well-being of a third party.EOB: Explanation of Benefits; statement to a provider showing the status of thatprovider’s outstanding claims with the insurer issuing the EOB (A.K.A. EOP –Explanation of Payment).EVS: Eligibility Verification SystemExpedited Member Grievance: A medical necessity determination grievance regardingan inpatient, acute partial, acute residential, 23-hour bed admission, or other urgent oremergent service, as determined by the member or provider.Fraud: An unintentional or unintended deception or misrepresentation made by aperson with the knowledge that the deception could result in some unauthorized benefitto himself or some other person.GAF: Global Assessment of Functioning (GAF score); a measure of mental healthdisability.Grievance: Formal mechanism for a member to disagree with Community Care’s denialbased on medical necessity of authorization for the level of care that the member andprovider deem is indicated. Filing a standard or expedited grievance starts a formalreview process. Community Care remains obligated to continue care for the memberuntil the grievance is resolved—up to a ruling from the state Department of Health.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 122

ICM: Intensive Case Management; a Community Care HealthChoices (Medicaid,Medical Assistance) covered service that includes coordination of multiple levels andtypes of services for a member with complex or rapidly changing care needs.LOC: Level of Care; inpatient versus partial hospitalization versus outpatient.LOF: Level of Functioning; a general term that includes specific measures such as GAF(Global Assessment of Functioning) scores.LOS: Length of Stay; continuous service days for an admission to a facility or program.MA: Medical Assistance (Medicaid)MATP: Medical Assistance Transportation Program; provides transportation (forexample, to mental health appointments) for HealthChoices (Medicaid, MedicalAssistance) members.MCO: Managed Care Organization (see BHMCO and PHMCO)MIS: Management Information SystemsMOE: Multicultural Outreach EducationNAMI: National Alliance on Mental IllnessNCQA: National Committee for Quality AssuranceNEIC: National Electronic Insurance Corporation; licensor of Envoy software used tobatch process Community Care Behavioral Health Organization claims submittedelectronically.OIC: Other Insurance CarrierOMHSAS: Office of Mental Health and Substance Abuse Services; a component of theDepartment of Public Welfare that administers policies regarding mental health andsubstance abuse issues.PCP: Primary Care PhysicianPCPC: Pennsylvania Client Placement Criteria (for chemical dependency)PHMCO: Physical Health Managed Care OrganizationPOSNET: Point of Service Network; a data transmission system with an electronic cardreader that a Community Care provider can use with HealthChoices members’Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 123

Medicaid/Medical Assistance identification cards to verify that the individuals are eligibleto receive HealthChoices (Medicaid, Medical Assistance) covered services.PROMISe: Provider Reimbursement and Operations Management Information System;Office of Medical Assistance Program’s information management system that producesprovider Medical Assistance enrollment numbers. The Office of Mental Health andSubstance Abuse Services and Community Care require provider enrollment throughthe Office of Medical Assistance prior to rendering behavioral health services.PsychConsult MCO ® : The computer software database program Community Careuses to record and report data to each provider and member.RC: Resource Coordination; a case management service to meet a member’s need formultiple services and supporters.Routine: Routine outpatient services, other than psychological evaluations, areidentified related to member need when a behavioral health condition requiresassessment and/or treatment but there is no apparent imminent or impending risk to themember or others and no evidence that the member has significant function impairment.RTF: Residential Treatment FacilitySF-12: Short Form Health Survey (a level of function measure)SBPH: School Based Partial HospitalizationSupplemental Services: These services may be paid for by Community Care but arenot HealthChoices in-plan services.Urgent: The onset of a mental and/or nervous or substance abuse conditionmanifesting itself by serious symptoms such that the mental health or physical wellbeingof the enrollee will deteriorate unless the enrollee is treated by the provider within24 hours, or in a case in which the enrollee believes that urgent assessment is required.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 124

AppendicesCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 125

APPENDICESAPPENDIX A.1. Fraud, Waste, and Abuse Compliance and Auditing Policies andProceduresPOLICYCommunity Care has established a fraud, waste, and abuse (FWA) complianceprogram that complies with regulations set forth by the Office of Inspector General(OIG) of the Department of Health and Human Services and with the requirements ofthe Bureau of Program Integrity (BPI) of the Department of Public Welfare (DPW). TheOIG encourages health care organizations to establish programs to educate andattempt to control fraud, waste, and abuse in health care. Documents have beenpublished by the OIG that identify the minimum elements that should be included in acompliance program, as well as specific areas of concern to the OIG. The BPI has alsoissued guidance on the reporting of suspected fraud, waste, and abuse.Toward that end, billing compliance audits of our provider panel are routinely conductedto determine potential areas of fraud and abuse, as defined below, that may beoccurring. These audits are conducted on an ongoing basis by specially trained staff.Community Care will continuously monitor instances of potential or actual fraud andabuse in billing by using recognized standards acceptable to the Medicaid Program.Suspected or substantiated fraud and abuse under the HealthChoices contract will bereported by the Fraud, Waste, and Abuse Department to the Bureau of ProgramIntegrity, to the appropriate county designee, and to appropriate oversight entities.Community Care follows all Medicaid Program regulations and BPI directives whenconducting and reporting audit information. No claims or documentation regulations arecreated by Community Care. In addition, the Department of Public Welfare’s Medichecklist and the OIG’s LEIE list are used to verify that no providers sanctioned by the stateor federal regulatory authorities are participating in HealthChoices.DefinitionsFraud is defined by the BPI as “any type of intentional deception or misrepresentationmade by an entity or person with the knowledge that the deception could result in someunauthorized benefit to the entity or him/herself or some other person in a managedcare setting.” It includes any act that constitutes fraud under applicable federal or statelaw. Fraud may be found under the following conditions (the following list is intended asan example and not as a limitation):When a provider submits a bill for a service that was not provided.When a provider bills for a time period greater than the time actually spent withthe client.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 126

When a provider bills for the provision of a service that did not meet the servicedefinitions, performance specifications, state or federal regulations, oraccreditation standards customarily recognized in behavioral health care.Inappropriate or frequent referrals that may constitute a conflict of interest.Care authorizations to providers who may have personal or other financialrelationships with care managers.Other related claims or care management issues that may involve intentionaldeception or misrepresentation as referenced above.Abuse is defined by the BPI as “any practices that are inconsistent with sound fiscal,business, or medical practices, and result in unnecessary cost to the Medicaid Program,or in reimbursement for services that are not medically necessary or that fail to meetprofessionally recognized standards or contractual obligations (including the terms ofthe [HealthChoices] RFP, Agreement and the requirements of the state or federalregulations) for health care in a managed care setting.” It also includes recipientpractices that result in unnecessary cost to the Medicaid Program.Community Care works collaboratively and cooperates fully with all oversight entities,counties, and regulatory agencies including, but not limited to, the BPI, the Office of theAttorney General’s Medicaid Fraud Control Section, the U.S. Justice Department, theCenter for Medicare and Medicaid Services, and the Pennsylvania Office of InspectorGeneral.Procedures for Monitoring the Provider Network for Fraud, Waste, or AbuseThe Fraud, Waste, and Abuse Department utilizes a number of methodologies in orderto detect fraud, waste, and abuse. The initiatives include, but are not limited to:Conducting routine provider chart reviews.Data analysis of provider billing information, including comparing historical trends ofpeer and best practice thresholds.Cooperation and collaboration between the Provider Reimbursement and FWADepartments in order to be proactive in detecting or preventing FWA.Review and testing of edits that are in place within the claims system to preventduplicate payments or payments without authorizations.Investigation of all referrals including those submitted through the FWA Hotline andthe FWA e-mail account.Cooperation and collaboration with external investigators including the BPI, CMS,Medi-Medi, or other law enforcement agencies.The auditing process for routine audits is outlined below.a. The provider will receive a notification letter and a telephone call informing him orher that the provider has been selected for an audit. The provider is either given theexact date and start time of the on-site audit, or they receive a request for membercharts to be sent to Community Care for a desk audit.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 127

. The provider will also receive a list of members’ charts to be reviewed at this time.c. No documentation will be accepted after the audit day has passed. In the case ofdesk audits, no documentation will be accepted after the initial charts are receivedby the auditing team. After completion of the audit, an exit interview is conductedwith appropriate provider program directors and administrators.d. Providers are informed during the exit interview that any reimbursements owed toCommunity Care may be directly deducted from future claim payments. Directrepayment may also be requested. Payments are due to Community Care within 30days from the date of the audit results letter. This information is also explained in theaudit results follow-up letter that is sent to the provider within two weeks after thecompletion of the audit.e. If the routine audit reveals a pattern of suspected fraud, waste, or abuse, CommunityCare must report the activity to the BPI within 30 business days, in accordance withregulatory requirements and the Community Care Fraud and Abuse Policy andProcedure. The appropriate county/counties and/or oversight entity will be notifiedwithin the same 30 day time period.f. If the audit reveals an area of non-compliance involving any issues not reflective ofsuspected fraud, waste, or abuse, a letter may be sent to the provider withinstructions to follow regarding submission of a corrective action plan and a directiveto contact Community Care in writing within 30 business days with any questions,concerns, or appeals.g. If the provider does not contact Community Care within 30 business days with anyquestions or concerns, it is assumed that the provider agrees with the findings of theaudit and will comply with corrective actions plans and reimbursement plans, whereapplicable.h. After the 30 day waiting period has passed, a copy of the letter is forwarded to theCommunity Care credentialing and network management departments. Letters willbe forwarded to the county/counties and/or oversight entities whenever the lettersare sent out to the providers.i. Based on results of the original audit, Community Care may conduct a follow-upaudit within 3-6 months of the previous audit final disposition.j. On a periodic basis the FWA Department will share audit exception trends with theprovider community. The audit findings will be communicated to providers throughvarious channels which include but are not limited to provider newsletters and FWADepartment Provider Alerts.The auditing process for referral audits is outlined below.a. The FWA Department accepts referrals from external and internal stakeholders.b. Both external and internal referrals can be made anonymously. Internal referralscan also be submitted through the employee’s manager or director.c. The FWA Department notifies the appropriate regional director/directors and the Sr.Director of Network Management of external referrals that have been submitted, forexample, by members through our Fraud and Abuse Hotline, or by the membernotifying the care management or network departments, by the Bureau of ProgramIntegrity, or by a county administrator of one of the HealthChoices contracts.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 128

d. Each referral is unique and therefore the details for handling the referrals vary. Forexample, if a referral is submitted by a member alleging that prescribed servicesare not being provided but they believe that their provider is submitting claims forthose services, Community Care will request that the provider forward to the FWAdepartment the member’s record in its entirety. An examination of the time periodthat encompasses the allegation time period will be reviewed. The amount of timereviewed will vary from referral to referral. Community Care will then comparedocumentation to submitted claims in order to determine if the allegations havebeen substantiated.e. The Bureau of Program Integrity may also submit referrals directly to the FWADepartment. The appropriate regional director/directors involved as well as the Sr.Director of Network Management will be notified as necessary.Provider Fraud and Abuse Audit Appeal ProcedureCommunity Care provides a transparent review process that enables providers toappeal Fraud, Waste, and Abuse audit results. Oral and written instructions regardingthe appeal process are reviewed with providers at the conclusion of each audit.The audit appeal procedure is outlined below.a. The provider must submit a written notification via certified mail to the Fraud andAbuse auditor, postmarked within 10 business days from the date of their auditresults letter, of their intent to appeal any audit findings.b. If the provider does not submit their appeal to the FWA Department within 30business days, any subsequent request for an appeal will be denied.c. The provider must then submit, via certified mail, their detailed appeal in its entiretyto the FWA auditor, postmarked within 30 business days of the date of the originalaudit results letter.d. The appeal must include documentation supporting each claim line, including theclaim number, member name, date that the service occurred, service code, numberof units involved, monetary amount, and the rationale for the appeal for each item inquestion. Only specific documentation supporting provider disagreement with auditexceptions will be reviewed by the Provider Appeal Committee for considerationduring this appeal process.e. All documentation relevant to the audit will be forwarded to the Provider AppealCommittee and a decision will be rendered within 30 days of receiving all of theappeal information.f. The decision of the committee will be considered final and the provider will benotified in writing of the appeal decision.Community Care includes information about fraud and abuse concerns in member andprovider education materials. Along with information about how to identify suspectedfraud and abuse, Community Care encourages members and providers to reportsuspected fraud and abuse through the toll-free numbers that are provided to them.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 129

APPENDIX A.2. ConfidentialityPOLICYCommunity Care, our staff and agents, shall protect the confidentiality of all confidentialdata and information to which they have access. “Confidential” information is defined asany information from which the member could be identified. The purpose of this policy isto assure that all data and information obtained by Community Care, and ourrepresentatives, are maintained and used with the degree of confidentiality and securitythat the data and information warrant. In addition Community Care shall follow allfederal, state, and other regulatory guidelines about privacy and security of protectedhealth information (PHI).PROCEDUREGeneral Confidentiality ProvisionsCommunity Care has designated the privacy officer to oversee company policies andprocedures regarding confidentiality and privacy. The specific functions for which theprivacy officer is responsible include but are not limited to: Annual review of all confidentiality policies. Annual training of Community Care employees on confidentiality. Follow-up to concerns of members or providers regarding confidentiality.The Fraud, Waste, and Abuse (FWA) Department will assist the privacy officer withthese responsibilities as required and requested.Community Care employees, staff, and volunteers are required to sign CommunityCare’s “Statement of Confidentiality” agreeing to be bound by strict confidentialitypolicies and procedures, including all federal and state laws, and the Health InsurancePortability and Accountability Act of 1996 (HIPAA). Signed “Statements ofConfidentiality” are maintained by Community Care’s FWA Department.CommunityCare business associates potentially having access to confidential information arerequired to sign Community Care’s “Statement of Confidentiality” agreeing to be boundby Community Care’s strict confidentiality policies and procedures or must conform toequivalent provisions as determined by Community Care staff or legal counsel.Breach of the “Statement of Confidentiality” or equivalent is grounds forimmediate termination.When Community Care becomes aware of a breach in confidentiality: The privacy officer will alert senior management of the breach of confidentiality. An investigation regarding the breach of the member’s (or provider’s) confidentialitywill be conducted by, or under the direction of, the privacy officer. All necessary staff will be interviewed. Any physical material involved will be reviewed.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 130

Findings will be reported to senior management.If applicable, Community Care will alert the Secretary of Health and HumanServices, and any other state or federal government agencies, and the physicalhealth plan when necessary, of the breach in confidentiality.At times, Community Care may have interns, residents, or students who may beexposed to the member’s protected health information during his/her rotation. They arerequired to sign Community Care’s “Statement of Confidentiality” in the beginning oftheir rotation and review all confidentiality policies and procedures.Education related to the principles and procedures for maintaining confidentiality isrequired for all Community Care employees, staff, and volunteers at the time of hire andannually thereafter. When an employee, staff, or volunteer has a significant change inhis/her job title or assignments, his/her director/supervisor will review all confidentialitypolicies that pertain to his/her new assignments at the time of the transition.Documentation of confidentiality training will be maintained in the employee’s personnelfile located in Human Resources Department (HIPAA Section 164.530(b)(1)).Community Care considers the following data and information to be confidential: Member identifiable data and information: that is, all data and information where themember is, or could possibly be, identified. Explicitly identifiable data include, but are not limited to, member name, socialsecurity number, medical record number, health plan beneficiary numbers, accountnumbers, certificate/license numbers, or other identifier that can be directly linked toa specific individual. Implicitly identifiable data include, but are not limited to, member address, telephonenumber, fax numbers, electronic email addresses, date of birth or other suchinformation that, alone or in combination with other available information, can lead toidentification of a specific individual. Practitioner specific data and information, including but not limited to, that used fornetwork development, credentialing, performance evaluation, quality assurance,quality improvement, and peer review. A practitioner’s name, professional degree, status as a member of CommunityCare’s practitioner network, business address, business telephone number, andspecialty/specialties or self-identified areas of special interest are not consideredconfidential when disclosed for legitimate business purposes. Data and information related to a practitioner’s racial, cultural or ethnic background,age, religious affiliation, sexual orientation, and ability to communicate in languagesother than English, is confidential unless the practitioner explicitly authorizes therelease of this information. Practice or group specific and facility specific data and information, including thatthat is used for but not limited to, network development, organizational assessmentand contracting, performance evaluation, quality assurance, and qualityimprovement.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 131

A Facility or group practice name, status as a participant in Community Care’snetwork, business address, business telephone number, and services offered arenot considered confidential when disclosed for legitimate business purposes.Community Care’s business data and information considered confidential includes but isnot limited to: Salaries. Policies and procedures. Finances. Business plans. Practitioner, practitioner group, and facility participants in Community Care’s networkwhen such information is not being released for legitimate business purposes. Proposals to potential or current customers. Information disclosed to Community Care in confidence by a third party. Information including quality assurance, quality improvement and performanceevaluation data and information where practitioners, practitioner groups, or facilitiesare not individually identifiable.Community Care has an array of security provisions to protect confidential data andinformation, including: Differential access based on job responsibilities to information maintained inCommunity Care’s information system. Physical lock and key arrangements. Electronic security systems. Mandatory compliance with Community Care’s Statement of Confidentiality.The following provisions are in effect for all Community Care representatives: Divulging computer passwords and security system pass codes is prohibited. Building access codes and keys may not be shared with any individual who does nothave the right to such access codes or keys. All computers that have the ability to access confidential data or information mustbe:• Protected with a confidential log-in password.• Turned or logged off at the end of the workday.• Protected with a confidential screen-saver password in the event that thecomputer is turned on and logged on while the computer user is away from his orher work area.Community Care’s agents, contractors, employees, staff, and volunteers may notaccess or view confidential data or information unless required by his/her duties orresponsibilities for, or on behalf of, Community Care. The “Statement of Confidentiality”includes a statement that an employee has access to sensitive and confidentialinformation and by signing this statement he/she agrees not to access information fromany source(s) that is not needed to perform his/her job duties.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 132

Another part of the “Statement of Confidentiality” is that only the minimum necessaryinformation is used by any employee at Community Care to perform his/her job duties.Community Care’s expectations are that only the minimum amount of informationneeded by our employees is used.Community Care’s Compliance and IS Departments oversee and monitor employeeaccess to member confidential data. Community Care’s agents, contractors, employees,staff, and volunteers may not discuss confidential data and information in an area whereindividuals, including other Community Care agents, contractors, employees, staff, andvolunteers who do not have the right to know about the information, may overhear theinformation.All confidential data and information must be maintained in a manner that preventsaccess by individuals who do not have a right to access the data and information.All physical media, including but not limited to paper, magnetic, and optical, used tostore confidential data and information must be stored under a double lock system.All physical media containing confidential information that are still in use byCommunity Care agents, contractors, employees, staff, and volunteers at the end ofthe day must be locked in that individual’s desk or in another secured storage area.All desks or secured storage areas must be in areas with keyed entry, maintaining aminimum of a dual-key system.All physical media containing confidential information that are no longer needed byCommunity Care agents, contractors, employees, staff, and volunteers must bereturned to locked master storage at the end of the day.All electronic media containing confidential information must be password protected.The transfer of confidential information for legitimate business purposes betweenCommunity Care’s agents, contractors, employees, staff, and volunteers in their officialcapacities as representatives of Community Care, is considered an internal transfer,even though they may be in different physical locations. The data they receive may bedecoded or “aggregate data” to protect the member’s health information.The internal transfer of all confidential data and information must be conducted in amanner that limits potential access by individuals who do not have a right to access thedata and information. Each director will determine the specific access and confidentialinformation his/her employees will need to access, in order for them to carry out his/herjob duties. (HIPAA Section 164.504(f)(2)(iii)When not hand-carried and personally delivered to the recipient, physical mediacontaining confidential data and information must be placed in a sealed envelopemarked “confidential.” Confidential data and information sent by facsimile must beara prominent confidentiality notice similar to the following: “This facsimiletransmission contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this message in error,please notify the sender by facsimile or telephone and destroy this document.”Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 133

Confidential data and information sent by email must be flagged as confidential andbear a confidentiality notice similar to the following at the beginning of the message:“This email contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this email in error, pleasenotify the sender by return email, securely delete this file, and any electronic ormagnetic copies, and destroy any paper copies.”Protected health information will not be transmitted via email.Confidential data and information no longer required for legitimate businesspurposes must be destroyed in a secure manner.Paper records must be thoroughly shredded.Magnetic files must be deleted in a manner that does not permit the files to beundeleted; for example, by reformatting a floppy disk using the “secure” formatoption.Optical storage media must either have the files securely deleted or, if this is notpossible, the storage media must be destroyed.If the receiver does not have the necessary means to destroy this information, theymust return the information back to Community Care in order for it to be destroyed.The transfer of confidential information other than to Community Care’s agents,contractors, employees, staff, and volunteers in their official capacities asrepresentatives of Community Care is considered an external transfer and must bemade in accordance with Community Care’s procedure on Disclosure of Information.Oversight of Confidentiality PracticesCommunity Care’s privacy officer is responsible for:Approving and annually reviewing all policies and procedures related toconfidentiality.Identifying, developing, and implementing mechanisms to oversee theimplementation and application of Community Care’s confidentiality policies andprocedures.At least annually, the privacy officer, in collaboration with the FWA Department, willevaluate ways to:Reduce the collection of member identifiable data and information.Aggregate or de-identify (the process of separating medical information frompersonal identification such as, removing a name or social security number in orderto prevent the identification of a specific member) such data and information asclose to the collection point as possible by surveying Community Carerepresentatives, conducting focus groups with Community Care representatives, andreviewing complaints.Community Care has identified circumstances necessitating special protection ofmember identifiable data and information as described in the procedure on Handling ofCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 134

Member Identifiable Information. Community Care acknowledges that additionalcircumstances necessitating such special protection may also arise (HIPAA 164.522).All requests for special protection of member identifiable data and information notaddressed in the policy referenced above shall be referred to the privacy officer. The privacy officer will consider the request and determine whether the requestshould or should not be honored. If the privacy officer determines that the request should be honored he/she will sendthe member a letter within 30 days including:• Notify the requestor of his/her decision.• Determine the mechanism to adhere to the request.• Update the procedure on Internal Handling of Member Identifiable information toreflect the addition. If the privacy officer determines that the request should not be honored he/she willsend the member a letter including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.• The name, or title, and the telephone number of the contact person for the nextstep.All member and practitioner concerns regarding confidentiality shall be logged ascomplaints and processed through Community Care’s complaint and appeals process(HIPAA Section 164.530(a)(1)(ii)).The privacy officer will be notified by the Complaint and Grievance Departmentabout complaints regarding privacy or confidentiality.The privacy officer or his/her designee will maintain a log with all complaints orgrievances dealing with confidentiality and privacy.The privacy officer or his/her designee will work with the Complaint and GrievanceDepartment on resolving complaints dealing with confidentiality and privacy.The privacy officer is responsible for reviewing requests for access to memberidentifiable data and information from all sources (internal, external, and businessassociates) and may enlist the cooperation of the FWA Department and medicaldirector as appropriate.In determining the time frame within which to conduct such a review, the privacy officeror medical director, if appropriate, will consider the potential benefit to the membershipfrom the requested access to data and information. For example, health outcomes maybe improved if access is granted to information on diagnosis so that a healthmanagement or preventive health program can be implemented.In the event that Community Care would participate in a research study, the medicaldirector, in collaboration with the privacy officer, is responsible for reviewing all requeststo access confidential data associated with a research project.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 135

The medical director or his/her designee will request a description of the purpose forthe requested information from the business associate.All requests for de-identified information will be recorded in the Request for DeidentifiedInformation log.Each request will be reviewed individually.For each request, Community Care will determine how this information will be deidentified.If Community Care is able to reduce the amount of information requested while stillmeeting a business associate’s request, we will do so.Community Care will develop a code to de-identify this information (HIPAA164.514(c). This code will be unique with each request for information. This code willnot be released to the business associate, and each code will be kept in the Requestfor De-identified Information Log. Only the medical director or his/her designee willhave access to this log.The medical director will present the request for information to the OutcomesCommittee for final approval.When the privacy officer receives the decision from the Outcomes Committee; theywill notify the requestor in writing, confirming if the requested information will bereleased, the manner in which it will be released, and how the information will be deidentified.If Community Care did not grant the request for information, a briefexplanation of the reason will be given instead.Once this has all occurred, the member will be contacted by Community Care to seeif he/she would like to participate in any active clinical research activity. CommunityCare is required to receive the member’s authorization prior to the release of anyinformation to a business associate for research purposes. If the member agrees toparticipate in the study and once the signed authorization is received from themember, the information will be released to the business associate conducting theresearch.If the member declines to take part of this study, his/her coverage will not beterminated with his/her refusal to participate.Collecting and Using Member Identifiable InformationCommunity Care collects and uses only the minimum necessary member identifiabledata and information routinely in the performance of our work. Community Careemployees are required to sign a “Statement of Confidentiality” when hired, agreeing tobe bound by Community Care’s strict confidentiality policies and procedures and allfederal and state laws.Community Care considers the following as member identifiable information, but it is notlimited to that listed below. This information used alone or in any combination mayidentify the member (HIPAA 164.512(b)(2)(i).NameAddress (es)Zip CodeCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 136

Diagnosis (es)Treatment DatesDate of BirthDate of DeathTelephone Number (s)Fax NumberElectronic Mail AddressSocial Security NumberUtilization Record ID NumberHealth Plan Beneficiary Number (s)Account Number (s)Certificate/License NumberDriver’s License NumberWeb Universal Resource Locators (URL’s)Any unique identifying number, characteristic, or code that Community Care createdthat if external sources deciphered the code they could identify the member.There are times when disclosures of protected health information are made on a routineand recurring basis, to providers for the purposes of treatment, payment, and healthcare operations. (HIPAA Section 164.514(d)(3)). These disclosures are a vital part ofour daily performance and may not be restricted. The provider identification is verifiedby our caller ID system as well as by the provider supplying specific identifyinginformation pertaining to the member, e.g., member ID and Social Security Numbers.Community Care staff identifies themselves to providers with their names, titles, andspecific identifying information pertaining to the member. If at any time there is aquestion as to the identity of the caller, staff members are instructed to take the name ofthe caller, the facility that is calling, and a telephone number where the call can bereturned. The contact and telephone number are verified before the call back is madeand any information is divulged.While Community Care does not maintain a medical record, Community Care doeskeep a utilization record. Per HIPAA (Section 164.501) a designated record set whichCommunity Care refers to as a utilization record is – a group of records maintained byor for Community Care, used, in whole or in part, by Community Care to make decisionsabout the member or provider, which may contain the following but is not limited to:The medical and billing records about the member or provider.The enrollment, payment, claims adjudication, and case or medical managementrecord systems maintained by Community Care.In accordance with HIPAA Section 164.524, the member may request to restrict thisinformation if desired. The member has the right to request at any time to restrict thecollection, use, or disclosure of his/her protected health information. The member maywrite a letter to the privacy officer at Community Care, requesting to restrict thedisclosure of his/her protected health information. The letter must include what specificinformation the member wants restricted, the member’s signature, and it must be dated.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 137

The privacy officer will review the member’s request and will respond in 30 days inwriting if this information is on site. If the information that the member is requesting isnot on-site, Community Care will retrieve the information within 60 days.If needed, Community Care may extend the retrieval an additional 30 days provided thatthe member is sent a written letter with an explanation for the delay, and provide a datein which we will have this information. Community Care will only have one suchextension of time for each request. If the restriction of protected health is granted:The privacy officer will send a letter to the member informing him/her howCommunity Care will limit his/her information.The privacy officer will oversee the process to restrict the protected healthinformation.This granted request for restriction of protected health information will be recorded inthe Member’s Request to Limit Protected Health Information Log, which ismaintained by the privacy officer or his/her designee.The privacy officer will notify the manager of the file room to have the member’s filepulled.The privacy officer or his/her designee will place on the front of the member’sutilization record a sticker.The sticker will have in writing on it “RESTRICTED INFORMATION.”If this file is requested by an employee, the file room clerk must see the privacyofficer, or his/her designee, to receive permission to process the request of this file.Once the employee is finished with this file and returns it to the file room, the fileclerk must alert the privacy officer or his/her designee that the file has beenreturned.The privacy officer will notify all necessary department managers of the member’srequest to limit his/her protected health information.PsychConsult will contain an alert notifying staff that this particular member’srecords are restricted.If the Member’s request is denied the privacy officer will:Record in the Member’s Request to Limit Protected Health Information Log that therequest was denied.Send the member a letter within 30 days of the decision including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.• The name, or title, and the telephone number of the contact person for the nextstep.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 138

Community Care has the right to deny any request made by the member:That will interrupt daily operations to carry out treatment, payment, and health careoperations.If there is information subjected to the Clinical Laboratory ImprovementsAmendment of 1988, 42 U.S.C. 263a, to the extent the provision of access to theindividual would be prohibited by law: or Exempt from the Clinical LaboratoryImprovements Amendment of 1988, pursuant to 42 CFR 493.3(a)(2) (HIPAA164.524).If the information was compiled for a civil, criminal, or administrative action orproceeding.If the information involves the member currently in a correctional institution.If the member’s records are subject to the Privacy Act, 5 U.S.C. 552a, the membermay be denied the right to restrict or limit the use of his/her information under thisact.The member has the right to have his/her denial reviewed by a licensed health careprofessional who was not part of the original decision to deny. The member must write aletter to Community Care’s privacy officer requesting that his/her denial be reviewed.Community Care has designated our medical director to be the licensed health careprofessional to review this request. Community Care’s medical director must determinein a reasonable time, whether or not to grant or deny the member’s access requestbased on the above. A letter must be sent to the member with the medical director’sdecision.If the medical director’s decision is to grant the member’s request to the restriction thenproceed as above. If the opinion of the medical director is still to deny the request, aletter with this decision must be sent to the member including the reason for the denial,and an explanation of Community Care’s complaint and grievance process, includingthe name, or title, and the telephone number of the contact person for the next step.At any time the member may lift the restriction of his/her protected health information bywriting a letter to Community Care’s privacy officer requesting the restriction be lifted.Community Care provides to members the Notice of Privacy, which describes the usesand disclosures of protected health information. The Notice of Privacy is sent to allmembers.Community Care uses the following methods to notify subscribers of Community Care’sroutine collection and use of member identifiable information:When Community Care is responsible for managing the enrollment process,subscribers are notified in writing at the time of enrollment of Community Care’sroutine collection and use of member identifiable information.In most instances, Community Care is not responsible for managing the enrollmentprocess. To ensure that all subscribers are notified of Community Care’s routineCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 139

collection and use of member identifiable information, some of the followingmechanisms are used:The health plan may distribute the information to its members.Members may be notified in Community Care’s Member Handbook or via membernewsletters that are mailed throughout the year with updated information.The member may request to have this information sent to a different address orlocation then where they are currently residing. They may write a letter to the privacyofficer at Community Care or call member services and inform us as to where theywould like the information sent (HIPAA 164.522(b)).A Notice of Privacy authorizing uses of member identifiable information is posted onCommunity Care’s website and members are informed of this posting via printedmaterials such as newsletters with a note that Community Care will provide theNotice of Privacy in written form upon request.Whatever the communication mechanism, the following language, or equivalent, is usedto notify subscribers of Community Care’s routine collection and use of memberidentifiable information: “Community Care uses information about you and yourdependents (if applicable) to enable us to verify eligibility for services; authorizetreatment; pay claims; coordinate care; resolve inquiries, complaints, and appeals;improve the care and service rendered by Community Care and its network ofpractitioners and facilities; and meet regulatory requirements and accreditationstandards. If we use information for reasons other than those described above, we willremove any portions of the information that could allow someone to identify you or yourdependent, or we will contact you or your dependent to ask for written authorization touse the information.”Community Care does not disclose protected health information for underwritingpurposes.Handling of Member Identifiable InformationAll data and information where the member or subscriber is, or could possibly be,identified are confidential. An individual’s status as the member or subscriber isconsidered confidential member identifiable information. A treatment record is a confidential document that is the record of privilegedcommunication between a member and a health care practitioner or facility. Community Care may obtain copies of treatment records for legitimate businesspurposes. Member identifiable information may not be divulged by telephone without firstverifying the identity of the other party. A case number or social security number and date of birth may be used to verify theidentity of an individual claiming to be a member or subscriber. If there is suspicion about the identity of an individual, even when such person cansupply a correct case number or social security number and date of birth, theCommunity Care representative should seek additional verification or requestassistance from a supervisor or manager.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 140

The member requesting information about his or her treatment should be referred tothe treating practitioner.Member identifiable information may not be disclosed to the member’s relatives orfriends except as described in the Disclosure of Information policy and procedure.Data and information derived from treatment records, utilization management records orother clinical sources shall not be considered confidential if they are de-identified orcombined and aggregated with other data and information in a manner that precludesthe identification of specific members. When considering the adequacy of suchaggregation or de-identification to maintain the member’s confidentiality, the CommunityCare representative disclosing the data or information must consider what other data orinformation may be available to the recipient that could enable the recipient of theinformation to identify the specific member.Members have the right to request special limits on access to member identifiableinformation. For example, the member who is also an employee of Community Caremay request that information on his or her treatment be afforded special protection.The following table describes circumstances that Community Care has determinedcreate a right to special protection of member identifiable data and information and themechanism that Community Care has implemented to adhere to the request:Reason for Special Protection ofProtected Health InformationThe subscriber is a staffmember/employee (or a familymember) or volunteer at CommunityCareMechanism to Adhere to RequestNo clinical information is maintained inCommunity Care’s information systemother than routine eligibility dataClinical reviews are conducted by themedical director, designatedprofessional advisor, or Chief ClinicalOfficerClaims adjudication is handledmanually by the department supervisorInforming Members about ConfidentialityCommunity Care prepares information, written at a 4 th grade reading level, for membersthat describes Community Care’s confidentiality policies and procedures. Theinformation covers the following topics:Collecting and using member identifiable information, including provisions for routinenotification of the collection and use of member identifiable data and information.Use of authorizations and ability to give informed authorization.Access to protected health information.Internal protection of protected health information across the organization.Member access to protected health information.Disclosure of Information.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 141

Protection of information disclosed to plan sponsors or employers.A member’s Right to Amend Protected Health Information.Right to an Accounting of Disclosures of Protected Health Information.If the member feels that his/her protected health information has been released or usedinappropriately, they have the right to file a complaint. They may either file the complaintby calling member services or writing a letter to Community Care’s Complaint andGrievance Department. They may also file a complaint with the Secretary of Health andHuman Services who oversees the HIPPA regulations.As part of the HIPAA regulations, members are notified via a Privacy Notice ofCommunity Care’s privacy policies and how Community Care limits and protectsprotected health information. The Privacy Notice is sent to all members detailing ourprivacy policies and how we will maintain his/her confidentiality. Changes made to thePrivacy Notice or policies dealing with privacy and confidentiality will be sent to themember. Notification will be through the member’s update/alert including a descriptiondetailing the change(s) and when the change will occur. Community Care will give themember a 60-day notice prior to the change becoming effective.Ability to Give Informed AuthorizationCommunity Care obtains special authorization to release member identifiableinformation as described in the Disclosure of Information policy and procedure.Community Care considers the following individuals capable of giving validauthorization for the release of member identifiable health information:The member, who has reached the age of majority as identified by CommunityCare’s eligibility data is capable of giving informed authorization on his or her ownbehalf unless Community Care has received notification that the individual has beenadjudicated incompetent.The legal guardian, natural or adoptive parent of a minor, as identified in CommunityCare’s eligibility data is capable of giving informed authorization on behalf of theminor unless Community Care has been informed that the parent has beenadjudicated incompetent, is not the legal guardian, or the minor has been legallyemancipated.An emancipated minor is capable of giving informed authorization on his or her ownbehalf. If not already on file with Community Care, Community Care will requestproof of the minor’s status from the minor before honoring the authorization.A legally authorized representative is capable of giving informed authorization onbehalf of the individual he or she represents. Community Care requires written proofof the individual’s status as legally authorized representative and that the statuscovers the area for which the authorization is being sought.Community Care extends all reasonable effort to develop and maintain anaccurate and efficient system for member information.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 142

Having established such a system, Community Care reasonably relies on theabsence of information indicating that the member or parent of a minor has beenadjudicated incompetent and that a parent is not a minor’s legal representative.Verifying the accuracy of the absence of such information would place an undueburden on Community Care and in most instances would require a breach ofconfidentiality.When Community Care is informed that the member is unable to give specialauthorization for the release of information, Community Care will acceptauthorization from, and/or release records to, a representative legally authorizedto release or receive the member’s personal health information. Community Carerequires written proof of the individual’s status as a legally authorizedrepresentative and that the status covers the area for which the authorization isbeing sought.Individuals capable of giving valid authorization for the release of memberidentifiable health information are also entitled to have access to suchinformation except as follows: Parents or guardians of children age 14 years orover may not have access to the child’s health information without authorizationfrom the child.Member Access to Utilization Records/Protected Health InformationCommunity Care does not provide direct care or treatment to members.In the event that Community Care intends to become a direct provider of careand treatment, Community Care will develop policies and procedures thataddress:How members can access their medical records if permitted.A process whereby members may restrict, access, amend or have an accounting oftheir medical files that are under Community Care’s control.In accordance with HIPAA Section 164.524, the member may access his/herutilization record if desired. The member may request to view his/her utilizationrecord by writing a letter to the privacy officer at Community Care.The privacy officer reviews the member’s request and will respond within 30 days.If the information requested by the member is not on site, Community Care willretrieve the information within 60 days.If needed Community Care may extend the retrieval an additional 30 days providedthat the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for the request.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 143

If a member is granted access to review his/her records:The privacy officer will oversee the process to view the protected health information.This granted request to review records will be recorded in the Members’ Request toReview Protected Health Information Log, which will be maintained by the privacyofficer or his/her designee.The privacy officer and or his/her designee will discuss with the member:• The format in which this information will be presented• How and where this information will be viewed (the member may choose toreview his/her records at Community Care or have the information mailed in anenvelope marked confidential to an address that they have specified).• If the member would like a summary of the information, or copies.• That a nominal fee may be charged by Community Care for postage, copying, orpreparation of the information (including the labor of copying the informationrequested).If Community Care is unable to accommodate the member’s request to view thisinformation, the privacy officer will send the member a letter describing:The decision.The reason for the denial.A description of the appeals process.The right to file an appeal along with the process for filing.The name, or title, and the telephone number of the contact person for the next step.Disclosure of InformationExcept as described in the procedures on Collecting and Using Member IdentifiableInformation, Community Care requests authorization from the member or the member’slegally authorized representative prior to disclosing the member’s protected healthinformation to external sources.Community Care will only disclose protected health information in accordance withthe most restrictive consent, authorization or other written legal permission from themember, unless otherwise specified by the member (HIPAA 164.506(e)).The member or the member’s legally authorized representative has the right to denythe request to release member identifiable information without any consequences tothe member or the member’s coverage.If member identifiable data and information are to be disclosed for purposes other thanthose described in the policies cited in paragraph 1 above, the authorization of themember or member’s legally authorized representative is required (HIPAA Section164.504).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 144

This includes, but is not limited to information:For research purposes.On behavioral health signs, symptoms, diagnoses, or treatment from a primary carephysician or other clinician not providing behavioral health care.That could result in a member being contacted by another organization for marketingpurposes.There may be times when Community Care needs to disclose information about themember without receiving informed authorization. These situations include, but arenot limited to (HIPAA Section 164.506(a)(3)(i)):Emergency situations where the member’s life or other lives may be at risk.Community Care may disclose information for the purpose of identification andlocation of the member with or without his/her authorization in response to a lawenforcement official’s request for information to identify, or locate a suspect, fugitive,material witness, or missing person. The following information may be releasedunder these circumstances (HIPAA 164.512(f)(2)):• Name and address.• Date and place of birth.• Social Security Number.• Date and time of treatment.• Date and time of death, if applicable.• Any description of distinguishing physical characteristics. (Height, weight,gender, race, hair/eye color, and any distinguishing traits, scars, tattoos, etc).When there is a substantial barrier to communication with the member andCommunity Care’s representative, using his/her professional judgment, believes theindividual’s consent to receive treatment is clearly inferred.When authorized by Community Care’s legal counsel to meet the requirements offederal, state, and local law.For public health activities as required by law (HIPAA 164.512(b)(i)):• To prevent or control disease, injury, or disability.• To report births and deaths.• To report child abuse or neglect.• To report reactions to medications or problems with products.• To notify people of product recalls, repairs, or replacements.• To notify a person who may have been exposed to a disease or condition.• To notify the appropriate government authority if we believe the member hasbeen the victim of abuse, neglect, or domestic violence.• Disclosures to federal, state, or county agencies that oversee Community Care,such as governmental monitoring of the health care system, Medical Assistance,government programs, and compliance with civil rights laws.• In regards to the care or payment related to the member’s health care (HIPAASection 164.510(b)).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 145

Under some circumstances, it may be necessary to obtain authorization verbally. Theuse of a verbal authorization should be approved in advance by Community Care’s legalcounsel or, if circumstances indicate a need for a rapid decision then by the member ofCommunity Care’s senior management team. If approved, two representatives ofCommunity Care must witness the entire process of obtaining verbal authorization torelease information.Community Care considers an authorization to release information to be valid only if(HIPAA 164.508(c)):It provides the name of the person (s) providing the information.It is in a language the member can understand.There is a purpose for the release.The specific information to be released (dates of treatment, and the exact type ofinformation to be released, i.e., mental health, drug and alcohol) is described.The member’s full name at the time of treatment and correct identifying information,e.g., date of birth and Social Security Number.The individual or entity authorized to receive the information is described.The expiration date of the authorization.The signature of the member or the member’s legally authorized representative (Ifthe authorization is signed by a personal representative of the individual, adescription of such representative’s authority to act for the individual).The release is obtained in a manner that complies with applicable law andregulations.There is a statement that treatment will not be affected if the member or member’srepresentative refuses to sign the authorization.There is a witness signature.There is a date of expiration for the authorization.There is a written statement on the authorization form that once this information isreleased to the recipient, this information may be subjected to re-disclosure by therecipient and no longer protected by this rule.There is a statement on the authorization form that if this information is used ordisclosed pursuant to the authorization, it may be subject to re-disclosure by therecipient and no longer be protected by this rule.There is a statement that the individual has the right to revoke this authorization inwriting, including the exceptions to the right to revoke, and a description of theprocess for the individual to revoke the authorization.Community Care will not release the information unless the form is completed.Prior to releasing information of previously signed authorization to releaseinformation, Community Care will review all authorization forms that are still in effectto ensure that they are compliant with HIPAA regulations.If a previously signed authorization is compliant with HIPAA regulations CommunityCare will continue to release the information until the authorization expires.If the authorization is not HIPAA compliant, then Community Care will contact themember within 60 days to obtain a newly signed authorization that conforms toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 146

HIPAA regulations.See the policy on Transition of Prior Consents and Authorizations for the completeprocedure.Community Care may use and disclose protected health information in order to improvebusiness operations and services to members. Protected health information that hadbeen de-identified and restricted may be released to business associates for activitiessuch as, but not limited to: oversight, auditing, or improving Community Care’s dailyoperations (HIPAA 164.504(f)(2)). Prior to releasing such information, businessassociates must sign a Business Associate Agreement. This agreement holds thebusiness associate accountable for the protected health information that they willreceive. Included in the agreement is (HIPAA Section 164.512(i)):A description of the permitted uses and disclosures of the limited protected healthinformation by the recipient, consistent with the purposes outlined in his/her proposalor contract.The requirement to limit access to who may receive the data.The requirement that the business associate will not use or disclose this informationother than as permitted by the agreement or otherwise required by law.The requirement that the business associate will take appropriate safeguards toprevent the use or disclosure of the information. If the business associate becomesaware that the information was tampered with or released mistakenly they mustnotify Community Care. Community Care will give the business associate anopportunity to investigate and rectify the situation.The requirement that the business associate will ensure that any agents, including asubcontractor, to whom the business associate provides the limited information,agrees to the same restrictions and conditions that apply to the business associate.The expectation that the business associate will not try to re-identify the informationor contact members.An explanation that if the Secretary of Health and Human Services requests thisinformation in order to oversee if Community Care is compliant with HIPAAregulations, the business associate will release the information to the Secretary.The requirement that, once the information is no longer needed the businessassociate will destroy it or return it to Community Care in order for it to be destroyed.A clause allowing the business associate contract to be terminated at any time ifCommunity Care has reason to believe that the business associate has violated anyof the above.Community Care may disclose protected health information that has been de-identifiedto Business associates for business functions that have been contracted. CommunityCare requires the following of the Business associate contract (HIPAA Section164.504(e)(ii)):The information given to them will not be used or further disclosed unless it isrequired or permitted by the contract or as required by the law (HIPAA SectionCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 147

164.504(e)(ii)(A)).They will take appropriate precautions with the information they are given (HIPAASection 164.504(e)(ii)(B)).In the event that someone discloses information they will report the breach toCommunity Care as soon as they become aware of it (HIPAA Section164.504(e)(ii)(C)).They will ensure any additional agents, including subcontractors, to whom thisinformation may become available to, follow the same restriction and conditions thatapply to them (HIPAA Section 164.504(e)(ii)(D)).The member may access, amend, or have an accounting of the information that isreleased to a business associates.The information released by Community Care will be available if requested by theSecretary of Health and Human Services in order to track Community Care’scompliance with HIPAA (HIPAA Section 164.504(e)(ii)(H)).At the termination of the contract or when this information is no longer needed, thebusiness associate has the necessary means to destroy this information or have thisinformation returned to Community Care in order for it to be destroyed (HIPAASection 164.504(e)(ii)(I)).A business associate’s contract may be terminated at any time if we feel thebusiness associate has violated any of the above (HIPAA Section 164.504(e)(iii)).Community Care may disclose protected health information about victims of abuse,neglect, or domestic violence without an authorization to law enforcement officials orgovernment agencies by a representative using his/her professional judgment (HIPAASection 164.512(c)(1)). If Community Care releases such information, it will promptlyinform the member that such a report has been made except when:Informing the member would put them in serious danger or harm.Community Care is unable to inform the member in which case the personalrepresentative may be informed that Community Care released this information.However, if Community Care believes the personal representative is responsible forthe abuse, neglect, or other injury then he/she would not be notified.Community Care may disclose protected health information without an authorizationto a law enforcement official:When required by law for the purposes of, but not limited to, investigating acomplaint, civil, or criminal charges. (HIPAA Section 164.512(f)) The informationrequested must first be forwarded to Community Care legal counsel for review.In the event that the member has died, for the purposes of alerting the law, ifCommunity Care has a suspicion that such death may have resulted from criminalconduct (HIPAA Section 164.512(f)(4)).If there is evidence of criminal conduct that has occurred on our premises (HIPAASection 164.512(f)(5)).If the member (HIPAA Section 164.512(f)(6)) contacts Community Care about acrime (commission or nature of one), the location of such crime or the victim (s) ofCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 148

such crime; and the identity, description, and location of the perpetrator of such acrime.In this latter instance, the Community Care representative will notify his/her directsupervisor of the situation, and will call 911 to report this information.Community Care does not collect information on the following, in regards to organ andtissue donation or the deceased member’s wishes, information about decedents,information for fundraising purposes, or information for marketing purposes. In the eventthe Community Care would collect information on any of the above, an appropriatepolicy and procedure will be drafted.Disclosure of Information to EmployersCommunity Care does not share member identifiable data or information withemployers without the authorization of the subscriber, member or member’s legallyauthorized representative and only the specific information requested will be releasedin accordance with all federal and state laws. All authorizations for the release ofinformation will be verified by Community Care prior to the information being sent.Community Care recognizes that the member or member’s legally authorizedrepresentative, and not a subscriber (unless the subscriber is also the member orthe member’s legally authorized representative) is the preferred individual fromwhom to obtain authorization to release member identifiable information to anemployer.Community Care also acknowledges, however, that current industry practice is forthe subscriber, and not each member, to sign authorization forms and otherdocuments at the time of enrollment. Requiring the signature of each member ormember’s legally authorized representative at the time of enrollment is impractical.Community Care accepts its role as an advocate of the members’ rights and willwork to effect change in the industry to increase protections for confidential memberidentifiable data and information. Community Care follows all state and federal lawsand regulations.When Community Care is responsible for managing the enrollment process,Community Care obtains authorization from a subscriber at the time of enrollment torelease the minimum member identifiable data or information to the employer.In many instances, Community Care is not responsible for managing the enrollmentprocess. If Community Care manages behavioral health benefits through an agreementwith a managed care organization (MCO), Community Care’s policy is to releasemember identifiable data or information to the MCO, knowing that in the absence of theMCO’s agreement with Community Care, the MCO itself would be responsible formanaging behavioral health benefits and would therefore have access to the memberidentifiable data or information.In any instance where Community Care must release member identifiable data orinformation to an employer, whether self-insured or fully insured, Community CareCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 149

must verify that the member has signed an authorization to release such data orinformation to the employer. Community Care will require that the employer agree inwriting to protect all member identifiable data and information from being used in anydecisions affecting the member (HIPAA 164.504(h)(3)(iv)).Many requests from employers for data and information can be fulfilled withdata and information that are not member identifiable: In instances where an employer requests member identifiable information,Community Care will inquire as to the proposed use of the data and information andattempt to meet the need with data and information that are not member identifiable,for example aggregated data or information. In instances where member identifiable data or information is required, CommunityCare will ensure that an authorization for the release of information is signed by themember prior to releasing implicit data to the member’s employer. In all instances, Community Care only discloses the minimal information necessaryto accomplish the purpose of the disclosure.Handling of Practitioner Specific InformationCommunity Care considers practitioner specific data and information, including but notlimited to, that used for network development, credentialing, performance evaluation,quality assurance, quality improvement, compliance auditing and peer reviewconfidential to the extent permitted by law.A practitioner’s name, professional degree, status as the member of CommunityCare’s practitioner network, business address, business telephone number, andspecialty (ies) or self-identified areas of special interest are not consideredconfidential when disclosed for legitimate business purposes.Data and information related to a practitioner’s racial, cultural or ethnic background,age, religious affiliation, sexual orientation, and ability to communicate in languagesother than English, is confidential unless a practitioner explicitly authorizes to therelease of this information.Community Care’s credentialing and recredentialing applications request that suchinformation be supplied at the discretion of a practitioner.The credentialing and recredentialing applications state that if such information issupplied, Community Care may use and disclose only the minimum amount ofinformation to members or appropriate individuals for purposes of meeting a specificMember needs or requests when making referrals.Practitioner files are maintained in a locked room or locked file cabinet when not inuse by credentialing staff or the Credentialing Committee. Practitioner files stored inelectronic, magnetic, or optical format are protected with a secure password.Access to practitioner files is limited to the network management, compliance, andcredentialing staff and the Credentialing Committee.Practitioners may review the information in his/her file upon request except for anyinformation from the National Practitioner Data Bank (NPDB) and peer (professionaladvisor) review information. Review of NPDB information is prohibited by FederalCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 150

statute. Each practitioner is informed of the right to review information in his/her file throughthe cover letter in the application packages for initial credentialing andrecredentialing. A practitioner may obtain a copy of his/her file. The request must be in writing. Credentialing staff will send a copy of a practitioner’s file to him/her within 10business days of receipt of the written request for the file. This file when mailed willbe sealed in an envelope marked confidential. NPDB information is not included. Peer review information is not included. Practitioners are notified by the credentialing staff of any information obtained duringcredentialing or recredentialing activities that varies substantially from theinformation provided by the practitioner. Practitioners have the right to correct erroneous information. Practitioners may submit any corrections in writing or additional documents to theCredentialing Department. Credentialing staff will document any verbal information or corrections provided by apractitioner in the file including the date and signature of the individual who obtainsthe information.Informing Providers about ConfidentialityThe following policies and procedures are included in Community Care’s ProviderManual and updated as needed:General Confidentiality Provisions.Oversight of Confidentiality Practices.Collecting and Using Member Identifiable Information.Informing Members about Confidentiality.Ability to Give Informed Authorization.Member Access to Utilization Records.Disclosure of Information.Disclosure of Information to Employers.Handling of Practitioner Specific Information.Practitioner Office Confidentiality.Practitioner Office ConfidentialityMember identifiable data and information maintained in paper-based or removablecomputer storage media must be maintained under lock and key, either in lockedcabinets or in a locked area.Member-identifiable data and information includes, but is not limited to, medicalrecords, appointment books, patient reminder cards, correspondence, laboratoryCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 151

esults, billing records, and treatment plans whether maintained on paper, magneticdisk or tape, optical disk, or any other removable storage medium.These paper-based records and removable computer storage media must be lockedexcept at times when the practitioner or another member of the office staff, who isauthorized to access treatment records, is present.When unlocked, these paper-based records and removable computer storage mediamust be maintained in a secure location where they are not accessible tounauthorized individuals.In addition, when unlocked, these paper-based records must be maintained in amanner that their content is not visible to unauthorized individuals.Computers used to store member identifiable data or information must be protectedwith a password.Password protection is not required if all persons at the practice site are authorizedto access, for legitimate business purposes, the member identifiable data orinformation stored on the computer; and the computer is located in a secure locationnot accessible to unauthorized individuals.When a computer is used to store member identifiable data or information, themonitor is positioned such that it is not visible to unauthorized individuals.If email is used to transmit member-identifiable data or information, the email isflagged as confidential and a confidentiality notice is prominently displayed at thebeginning of the email that conveys a message substantively similar to the following:“This email contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this email in error, pleasenotify the sender by return email, securely delete this file and any electronic ormagnetic copies, and destroy any paper copies.”Facsimile machines are in secured areas where faxes may not be intercepted orviewed by individuals not authorized to access member identifiable data andinformation. If facsimile machines are used to transmit member identifiable data orinformation, a confidentiality notice is prominently displayed on the facsimile coversheet that conveys a message substantively similar to the following: “This facsimiletransmission contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this message in error,please notify the sender by facsimile or telephone and destroy this document.”Handling of Community Care’s Business InformationCommunity Care’s representatives and business associates may not releaseconfidential business data and information (as described in the procedure on GeneralConfidentiality Provisions) except for legitimate business purposes and within theframework of the representative’s job responsibilities or the business associate’snormal course of performing work for Community Care:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 152

As described in Community Care’s policies, procedures, program descriptions andwork plans, or as authorized by a member of Community Care’s seniormanagement.All requests for confidential business information which are not explicitly addressed andauthorized by Community Care’s policies and procedures or other official documentsshould be referred to the manager of the department for documentation and follow-up.All statements to the media including press releases and interviews are made by orauthorized by Community Care’s Chief Executive Officer.SubpoenasMember identifiable data and information must not be released if a subpoena isserved without first consulting Community Care’s legal counsel:The Community Care representative receiving the subpoena should immediatelysend the subpoena, via facsimile if necessary, to Community Care’s legal counsel.If the Community Care representative receiving the subpoena is not a member ofmanagement, he or she should immediately contact his or her supervisor to act onthe matter.Legal counsel, in conjunction with appropriate Community Care staff, employees,and the treating practitioner, will determine the appropriate course of action.When the information is needed to prevent further harm to the member, CommunityCare may release protected health information in response to a law enforcementofficial’s request with or without the authorization of a member who is suspected ofbeing a victim of a crime (HIPAA Section 164.512(f)(3)).Information may be released to law enforcement officials for court proceedings or aninvestigation, after it is forwarded to Community Care’s legal counsel. CommunityCare will ensure that the proceedings and persons requesting the member’sinformation have made a good faith attempt to contact the member, or his/her legallyauthorized representative, to inform him/her that their protected health information isbeing requested before it is released (HIPAA Section 164.512(e)).If the officials are unable to locate the member and they have shown reasonable effortsin an attempt, then Community Care will release information if (HIPAA Section164.512(e)):There is documentation to support our efforts in trying to find the member.A written notice was sent to the member’s last known address and the member wasgiven sufficient time to respond or raise objections.Once time has elapsed:• Proof that there are no objections filed by the member.• If there are any objections filed, they have been resolved through the court or anadministrative tribunal.• The information released is only to be used for the litigation or proceeding.• Once this information is no longer needed then, Community Care requires thatCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 153

equestor destroy the information, or to return it so that it can be destroyed.A Member’s Right to Amend Protected Health InformationIn accordance with HIPAA (Section 164.526), the member has the right to amendhis/her protected health information if desired. The member may request to amendhis/her information by writing a letter to the privacy officer at Community Careincluding a reason why this information needs to be amended.The privacy officer will review the member’s request and will respond in writingwithin 30 days.If the information requested is not on site, then Community Care will retrieve theinformation within 60 days.If needed Community Care may extend the retrieval an additional 30 days provided;that the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for action.If the member is granted the right to amend his/her protected health information, theprivacy officer will oversee the process to amend the protected health information.The privacy officer or his/her designee will record the granted request to amendprotected health information in the Member Request to Amend Protected HealthInformation log, which will be maintained by the privacy officer or his/her designee.The privacy officer will inform the member that the original information will remainintact. The privacy officer or his/her designee and the member will discuss how thisinformation will be amended; including what type of statement will be attached to allfuture releases such as “this information, as requested by the member, wasamended.” The privacy officer will notify the manager of the file room to have themember’s chart pulled.A sticker will be placed on the front of the member’s utilization record that says:“AMENDED PROTECTED HEALTH INFORMATION.” The privacy officer or his/herdesignee will also write a brief statement to be included in the member’s file, on howthis information that was requested by the member was amended.There will be a flag in PsychConsult to inform Community Care employees that thisinformation was amended.Community Care’s privacy officer will write a formal notification alerting all thenecessary staff and providers that the member’s protected health information wasamended and include a brief statement on how and why.Once this process is completed the privacy officer or his/her designee will send awritten letter to the member including that his/her request to amend his/her protectedhealth information was granted, including a brief description on how it was amended.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 154

If the member is denied the right to amend his/her protected health information theprivacy officer, or his/her designee will:Record in the Member Request to Amend Protected Health Information Log that therequest was denied.Send the member a letter including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.• The name, or title, and the telephone number of the contact person for the nextstep.The member has the right to request in writing that Community Care attach astatement to all future releases such as “the member requested this information beamended and Community Care denied the request.”The privacy officer or his/her designee will record in the Member Right to AmendProtected Health Information Log that the member requested a statement similar tothe one above be attached to all future releases of information.The privacy officer or his/her designee will notify the manager of the file room tohave this member’s file pulled.A sticker will be placed on the front of the member’s utilization record that says:“SEE PRIVACY OFFICER BEFORE ANY INFORMATION IS RELEASED TOOUTSIDE SOURCES.” The privacy officer will need to see the information that isrequested before it is sent to ensure that the statement a member requested isincluded with the information.The privacy officer or his/her designee will also write a brief statement to be includedin the member’s file that the member requested to amend his/her protected healthinformation was denied.The member may also request that this statement be included with all futureinformation to be released.If the information the member is requesting to be amended is not the property ofCommunity Care, the member will be referred to the originator of the documents.If the originator of the protected health information is unable to act on the request (forexample, a practitioner who is no longer in practice), and Community Care’s privacyofficer feels the member’s written request is legitimate Community Care will amendthe information in its possession (HIPAA 164.526(a)(2)(i)).Right to an Accounting of Disclosures of Protected Health InformationThe member has the right to request that Community Care provide an accounting ofdisclosures of protected health information made by Community Care in the six years(or shorter time period) prior to the date in which the accounting is requested. (As perthe HIPAA Section 164.528.) Community Care is not required to track disclosuresprior to the implementation of the HIPAA Privacy Regulations.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 155

The member has the right to request an accounting of disclosures of his/herinformation by writing a letter to the privacy officer at Community Care.The privacy officer or his/her designee will review the member request and willrespond in 30 days.If the information requested by the member is not on site, Community Care willretrieve the information within 60 days.If needed Community Care may extend the retrieval an additional 30 days provided;that the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for each request.If granted, Community Care will release to the member an accounting of his/herdisclosed protected health information.The privacy officer or his/her designee will oversee the process to account fordisclosures of protected health information.This granted request for an accounting of protected health information will berecorded in the Member Request to an Accounting of Protected Health InformationLog, which will be maintained by the privacy officer or his/her designee.The privacy officer or his/her designee will notify the manager of the file room tohave the member’s chart pulled. The following will be included in the accounting ofdisclosures:• The date of the disclosure.• A brief description of the information that was released.• A statement on the purpose of the disclosure or a copy of the signedauthorization.• The name of a person or provider who requested this information. (CommunityCare reserves the right to deny the request for an accounting of disclosure ofinformation if divulging the name of the person who received information could bedetrimental to the member or the person to whom the information was disclosed.)• A brief statement of Community Care’s policy on Disclosure of Information.• If there was more than one authorized release of information during therequested time period then, the frequency, periodicity, or number of thedisclosures made is included.• If the information was for, or in anticipation of, a civil, criminal, or administrativeaction or proceeding, Community Care will not release the information.• A flag will be placed in PsychConsult to notify employees that the member askedfor an accounting of disclosures.Once this information has been compiled, the information will be mailed in anenvelope marked “Confidential” to the address that the member specifies.Each year the first request for the accounting of information is free. After this,Community Care may charge a reasonable fee for preparing the information, as long asmembers are notified.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 156

If the privacy officer determines that the request should not be honored, within 30 dayshe/she will send the member a letter including the decision; the reason for the denial; adescription of the appeals process; the process for filing an appeal; and the name/titleand phone number of the contact person for the next step.APPENDIX A.3. Supplemental ConfidentialityPOLICYIt is the policy of Community Care to protect the confidentiality of member information inits administrative functions and among its contracted health care providers. Specificprovider and member information is collected and used by Community Care to theextent necessary and appropriate to requirements relating to accountability functionsand for the delivery of efficient and high quality care and services.This Confidentiality and Disclosure Policy is intended to provide Community Carepersonnel with guidance concerning the disclosure of information relating to members,providers, services furnished to members, or other confidential information, whether theinformation was created by Community Care or acquired in connection with its businessactivities.Responses to requests for information from utilization records must comply withapplicable state and federal laws and regulations and The Health Insurance Portabilityand Accountability Act (HIPAA) regulations including 164.510 governing the release ofsuch information. Responses to requests for information should reflect a customerservice orientation but must also reflect an awareness of the potentially competinginterests of different customers of Community Care, e.g., employer groups and enrolledmembers. This policy also concerns confidentiality regulations related to theassessment, diagnosis, referral, case management, counseling, and treatment of themember, as well as confidentiality related to the complaint and grievance process.It is the policy of Community Care to adhere to all applicable laws, regulations andprotections with respect to assuring the confidentiality of member information and withthe specific requirements set forth at 42 CFR, Part 2 of the Federal Regulations, 255.5of the Pennsylvania Drug and Alcohol Abuse Control Act, the confidentiality of HIV-Related Information Act, the Mental Health Procedures Act and the Mental Health andMental Retardation Act of 1966 and all pertinent regulations. No information will bereleased without the specific authorization of the member except as noted in andconsistent with the attached specific directives and exceptions:CPL 032 Confidentiality Policy.Authorization to Release Confidential Information Form.Patient Record Retention Policy.Policy on Release of HIV-Related Information.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 157

Policy on Release of Information Related to the Treatment of Minors.Policy on Release of Information Related to Mental Health Treatment.Policy on Release of Information Related to Drug and Alcohol Dependency andTreatment.Policy on Community Care Staff Having Knowledge of or a Relationship with theMember.PROCEDURESConfidentiality: Terms and Disclosure PolicyCategories of Information - Community Care’s legal obligations with respect todifferent types of information vary. For the purposes of this policy, information isgrouped into the following categories:Claims Information - The member identifiable information, both medical and nonmedical,submitted by the member or the health care provider to Community Care on aclaim form for the purpose of obtaining payment for medical services. CLAIMSINFORMATION includes information submitted to complete an incomplete claim form,but does not include medical records or information generated by Community Care inconnection with utilization review, quality assurance, case management, complianceaudits, or other managed care activities.Medical Records - All member identifiable information within the member’s medical fileas documented by the attending physician or other medical professional and which iscustomarily held by the attending physician or provider hospital. Medical records maybe sent (following HIPAA guidelines) to Community Care in connection with utilization,compliance, or quality assurance activities, or may be furnished as supportingdocumentation to claims information. In Pennsylvania, the original medical record is theproperty of the provider.Utilization Record - A group of records maintained by or for Community Care, used, inwhole or in part, or for Community Care to make decisions about the member orprovider that may contain the following but is not limited to:The medical and billing records about the member or providerThe enrollment, payment, claims adjudication, and case or medical managementrecord systems maintained by Community Care.Aggregate Claim Information (“ACI”) - means all non-identifiable member informationconcerning medical claims.Member File Information - means the member’s enrollment application, records ofcommunications between Community Care and the member, records of administrativecorrespondence, such as referral forms, between practitioners and Community CareCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 158

concerning the member and the like. This information is typically maintained in what iscalled the “utilization record”.Community Care Proprietary Information- means information about the wayCommunity Care conducts business, including but not limited to trade secrets,confidential financial information, provider contract information, business associateagreements, and utilization management (UM) and quality management (QM)methodology created and utilized by Community Care. Community Care proprietaryinformation also includes usual and customary database information and specificcharge information. Descriptions of Community Care business practices routinelyincluded in responses to Requests for Proposals or otherwise made available to thepublic are not proprietary information. Director level personnel, in consultation withlegal services, are responsible for determining whether other information is proprietary.Patient Identifiable Claim Information – see “CLAIMS INFORMATION”Aggregate Claim Information (ACI) and Community Care Non-Medical ProprietaryInformation – Per State law Community Care is prohibited from releasing any claimsinformation or status to HealthChoices members.Confidentiality: Compliance with State and Federal LawsCommunity Care complies with all state and federal laws and regulations pertaining tothe disclosure of confidential member information and to assure that such confidentialinformation is not released without proper documentation, appropriate authorization,and in accordance with HIPAA regulations to contract holders and their minions.Community Care publishes and distributes a DPW approved Member Handbook to allMedical Assistance members. This handbook describes confidentiality protectionsincluding explanation of access to the member’s clinical records by oversight agenciesand access to records for quality and utilization oversight purposes. The MemberHandbook also advises members about the appropriate release of information formsneeded to send information in their utilization record to other providers of health care.In addition, Notice of Privacy statements are sent to all members in accordance withHIPAA privacy regulations.Notice to Accompany Information Released Pursuant to Written Authorization forDisclosureEach disclosure made to a third party with the member’s written authorization must beaccompanied by the following written statement:This information has been disclosed to you from records whose confidentiality isprotected by federal and Pennsylvania law including the Health Insurance Portabilityand Accountability Act of 1996. These laws and regulations prohibit you from makingany further disclosure of this information unless further disclosure is expressly permittedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 159

y the written authorization of the person to whom it pertains or as otherwise authorizedby such laws or regulations. A general authorization for the release of medical or otherinformation is not sufficient for this purpose.Release of HIV – Related InformationCommunity Care is in compliance with the Pennsylvania Confidentiality of HIV-RelatedInformation Act concerning disclosure of Member information related to HIV status andtreatment and to comply with the rules and regulations of the Health InsurancePortability and Accountability Act (HIPAA).Community Care will maintain the confidentiality of the member’s HIV-relatedinformation as defined in the Confidentiality of HIV-Related Information Act.Confidential HIV-related information as so defined includes the following:Any information which concerns whether an individual has been the subject of anHIV-related test.Whether an individual has HIV, an HIV-related illness, or AIDS.Any information which “identifies or reasonably could identify” an individual ashaving HIV, an HIV-related illness or AIDS.Community Care will not release HIV-related information, as defined above, eitherverbally or in writing, without first obtaining the written authorization of the memberor authorized legal representative. The written release must be accompanied by anotification prohibiting further disclosure without the written authorization of themember. The member must be informed of his/her rights of confidentiality as statedin the law. The release of information form contains a specific release of informationof HIV related information with the member’s/authorized legal representative’ssignature.Exception: Records may be disclosed without written authorization to the personsor entities defined in the following pertinent provisions of the Confidentiality of HIV-Related Information Act, attached. (Original copy on file. This is a reproducedstatement of the act)Limitations on disclosure - No person or employee, or agent of such person, whoobtains confidential HIV-related information in the course of providing any health orsocial service or pursuant to a release of confidential HIV-related information undersubsection (c) on page 127 may disclose or be compelled to disclose the informationexcept to the following persons: The subject. The physician who ordered the test, or the physician’s designee. Any person specifically designated in a written consent as provided for in subsection(c) on page 127. An agent, employee or medical member of a health care provider, when the healthcare provider has received confidential HIV-related information during the course ofthe subject’s diagnosis or treatment by the health care provider, provided that theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 160

agent, employee, or medical member is involved in the medical care or treatment ofthe subject. Nothing in this paragraph shall be construed to require the segregationof confidential HIV-related information from a subject’s medical record.A peer review organization or committee as defined in the act of July 20, 1974 (P.L564, No. 193), known as the Peer Review Protection Act 1 , a nationally recognizedaccrediting agency, or as otherwise provided by law, any federal or stategovernment agency with oversight responsibilities over health care providers.A person allowed access to the information by a court order issued pursuant toSection 8.A funeral director responsible for the acceptance and preparation of the deceasedsubject.Employee’s of county mental health/mental retardation agencies, county childrenand youth agencies, county juvenile probation departments, county or state facilitiesfor delinquent youth, and contracted residential providers of the above-namedentities receiving or contemplating residential placement of the subject, who:• Generally are authorized to receive medical information.• Are responsible for insuring that the subject receives appropriate health care.• Have a need to know the HIV-related information in order to ensure such care isprovided.The above named entities may release the information to a court in the course of adispositional proceeding under 42Pa.C.S. §§ 6351 (relating to disposition of dependentchild) and 6352(relating to disposition of delinquent child) when it is determined thatsuch information is necessary to meet the medical needs of the subject.Release of Information Related to Treatment of MinorsCommunity Care complies with all applicable laws and regulations governing theconfidentiality of and authorized disclosure of utilization records related to care providedto a minor, as defined under applicable law as a person under age 18.The obligation of Community Care to maintain the confidentiality of utilization records ofminor members is governed by specific federal or state laws and regulations.Generally, a minor under the age of 18 may not consent to treatment or to release ofrecords, except one who has graduated from high school, been married or pregnant,except as provided below:Drug and Alcohol Abuse and Dependency Services. The Pennsylvania Drug andAlcohol Abuse Control Act authorizes a minor suffering from the use of a controlledor harmful substance to consent to the provision of medical care or counselingrelated to diagnosis or treatment. The consent of the parent or legal guardian of theminor is not necessary to authorize medical care or counseling. Any physician orany agency or organization operating a drug abuse program that provides care andcounseling to a minor may, but is not obligated to, inform the parents or legalguardian as to the treatment given or needed.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 161

If minor consents to treatment or counseling related to the diagnosis or treatment ofdrug or alcohol abuse and dependency without the involvement of a parent orguardian, the written authorization of the minor will be obtained by Community Careprior to the release of patient utilization records.Mental Health Services. The Mental Health Procedures Act authorizes any person14 years of age or older who believes that he/she needs treatment and understandsthe nature of treatment to consent to examination and treatment. A parent orguardian may consent to treatment of children less than 14 years of age.Community Care will not release the utilization records of any member without thewritten authorization of the person providing consent to treatment.Significant Member Incidents: Reporting of Child Abuse. In accordance withapplicable law governing child abuse, providers are required to report all incidents ofsuspected child abuse. Community Care will ensure that a Childline phone numberis made available to providers and conspicuously listed in the Provider Manual alongwith the appropriate forms for reporting and documenting suspected incidents ofabuse.Release of Information Related to Treatment of Mental HealthCommunity Care complies with pertinent provisions of the Mental Health ProceduresAct, the Mental Health and Mental Retardation Act of 1966 and regulations promulgatedby the Pennsylvania Department of Public Welfare and set forth in the Mental HealthManual at 55 Pa. Code §§5100.31 et seq. defining appropriate release of informationrelated to mental health treatment.Persons seeking or receiving services from a mental health provider may expect thatinformation will be treated with respect and confidentiality so that trust and confidence intherapeutic intervention may develop. Mental health records subject to this policyinclude, but are not limited to, written clinical information, observations and reports, orfiscal documents relating to the member which are required or authorized to beprepared by the Mental Health Procedures Act or by the Mental Health and MentalRetardation Act of 1966, and any central files and reports which are required to bemaintained by the Department of Public Welfare or other statutes or regulationsregarding services for mental health programs.Community Care will not release the records of any Member, 14 years of age or older,who understands the nature of the documents to be released and the purpose ofreleasing them without the written authorization of the member.For the member who lacks this understanding, any person chosen by the member mayexercise this right (if that person is found by the administrative head of the facility or hisdesignee to be acting in the member’s best interest).If the member is less than 14 years of age or has been adjudicated legally incompetent,control over the release of records may be exercised by a parent or guardian.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 162

Exception: Records concerning persons receiving mental health treatment servicesmay be released without the written authorization of the member only in thosespecific circumstances defined in 55 Pa. Code §§5100.32, §5100.35, §5100.36 and§5100.38, attached. (This is a reproduction of the original document, 55 § 5100.32Mental Health Manual Pt.VII.)Nonconsensual release of informationRecords concerning persons receiving or having received treatment shall be keptconfidential and shall not be released nor their content disclosed without the consentof a person given under § 5100.34 (relating to consensual release to third parties),except that relevant portions or summaries may be released or copied as follows:• To those actively engaged in treating the individual, or to persons at otherfacilities, including professional treatment of State Correctional Institutions andcounty prisons, when the person is being referred to that facility and a summaryor portion of the record is necessary to provide for continuity of proper care andtreatment.• To third party payors, both those operated and financed in whole or in part byany governmental agency and their agents or intermediaries, or those who areidentified as payor or copayor for services and who require information to verifythat services were actually provided. Information to be released without consentor court order under this subsection is limited to the names, dates, types, andcosts of therapies or services, and a short description of the general purpose ofeach treatment session or service.• To reviewers and inspectors, including the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) and Commonwealth licensure or certification,when necessary to obtain certification as an eligible provider of services.• To those participating in Professional Standards Review Organization (PSRO) orutilization reviews.• To the administrator, under his duties under applicable statutes and regulations.• To a court or mental health review officer, in the course of legal proceedingsauthorized by the act or this chapter.• In response to a court order, when production of the documents is ordered by acourt under § 5100.35 (relating to release to courts).• To appropriate departmental personnel § 5100.38 (relating to child or patientabuse).• In response to an emergency medical situation when release of information isnecessary to prevent serious risk of bodily harm or death. Only specificinformation pertinent to the relief of the emergency may be released on anonconsensual basis.• To parents or guardians and others when necessary to obtain consent to medicaltreatment.• To attorneys assigned to represent the subject of a commitment hearing.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 163

Current patients or clients or the parents of patients under the age of 14 shall benotified of the specific conditions under which information may be released withouttheir consent.Information made available under this section shall be limited to that informationrelevant and necessary to the purpose for which the information is sought. Theinformation may not, without the patient’s consent, be released to additionalpersons, or entities, or used for additional purposes. Requests for information andthe action taken should be recorded in the patient’s records.Release to CourtsEach facility director shall designate one or more persons as a records officer, whoshall maintain the confidentiality of client/patient records in accordance with thischapter.Records shall comply with the following:• Whenever a client/patient’s records are subpoenaed or otherwise made subjectto discovery proceedings in a court proceeding, other than proceedingsauthorized by the act, and the patient/client has not consented or does notconsent to release of the records, no records should be released in the absenceof an additional order of the court.• The records officer, or his designee, is to inform the court either in writing or inperson that, under statute and regulations, the records are confidential andcannot be released without an order of the court. Neither the records officer northe facility director has any further duty to oppose a subpoena beyond stating tothe court that the records are confidential and cannot be released without anorder of the court; however, nothing in this section shall be construed asauthorizing such a court order.• If it is known that a patient has a current attorney or record for the givenproceedings, that attorney shall be informed of the request of subpoena, if notalready served with a copy, and shall be expected to represent and protect theclient/patient’s interests in the confidentiality of the records. The person whoserecord has been subpoenaed shall be notified of such action if they are currentlyreceiving services and their whereabouts are known, unless served with a copyof the subpoena. Those currently in treatment shall also be advised that theymay wish to obtain an attorney to represent their interests. In the case of personsno longer receiving services, the facility shall send this notification by certifiedmail to the last known address.• If a present or former patient sues a person or organization providing servicessubject to the act in connection with said patient’s care, custody, evaluation, ortreatment, or in connection with an incident related thereto, defense counsel forsaid service provider shall have such access to the present or former patient’srecords as such counsel deems necessary in preparing a defense. Counselreceiving such records shall maintain their confidentiality and shall limit thedisclosure of the contents thereof to those items they deem necessary to allowcounsel to prepare and present a proper defense.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 164

• All employees of a facility shall be informed of the rules and regulations regardingconfidentiality of records and shall also be informed that violation of them couldpotentially subject them to civil or criminal liability. Training for employeesregarding confidentiality remains the responsibility of the facility director.Departmental Access to Records and Data CollectionNotwithstanding, any part of this chapter to the contrary, employees of thedepartment shall not be denied access to any patient records where such access isnecessary and appropriate for the employee’s proper performance of his/her duties.The facility director shall make such decision, and shall be responsible for limitingaccess to those portions, which are relevant to the request.Any conflict as to access by an employee to patient records at State Hospitals shallbe resolved by the Regional Commissioner of Mental Health.Collection and analysis of clinical or statistical data by the department, theadministrator, or the facility for administrative or research purposes may beundertaken as long as the report or paper prepared from the data does not identifyany individual patient without his consent.Child or Patient AbuseNothing in this chapter shall conflict with the mandatory statutory or regulatoryrequirements of reporting suspected or discovered child abuse or patient abuse.Whenever a conflict exists between the reporting requirements of the Child ProtectiveServices Act (11 P.S. §§ 22012224), and the confidentiality of mental health records,the reporting requirements shall govern.Release of Information related to Drug and Alcohol Dependency and TreatmentCommunity Care complies with the Pennsylvania Drug and Alcohol Abuse Control Actand applicable State regulations at 4 PA. Code §255.5(b) and Interpretative Guidelinesissued by the Pennsylvania Department of Health, and federal regulations at 42 C.F.R.,Part 2, concerning circumstances of permissible release of records containinginformation on alcohol and substance abuse and dependency.All member records containing information as to drug and alcohol abuse or dependencyand treatment must be kept confidential. Such records may be disclosed only with themember’s authorization and only (I) to medical personnel exclusively for purposes ofdiagnosis and treatment of the member or (II) to government agencies exclusively forthe purpose of obtaining benefits due as a result of such drug or alcohol abuse ordependency.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 165

If the client has given written authorization for such release, certain information may bereleased to insurance companies and health plans to include (28 PA Code §709.28Confidentiality): Whether the person is or is not in treatment. The prognosis. Diagnoses on all five Axes. General peculiarities of the case. The provider may present his/her recommendations regarding the client’scontinuation with the treatment program. The nature of treatment. The structure of the program. The methodology of treatment and the treatment models that are utilized by theprogram. A brief description of progress. The provider may speak in general terms of the member’s progress or lack ofprogress as it relates to recovery. The provider may speak in general terms of the clients understanding of the diseaseconcept and their cooperation, or lack of, regarding the rules. A short statement of whether the person has relapsed into drug or alcohol abuseand the frequency of such relapse. Exception: In an emergency where the member’s life is in immediate jeopardy,patient records may be released without the member’s authorization to propermedical authorities solely for the purpose of providing medical treatment. Disclosure may be made for purposes unrelated to such treatment or benefits onlyupon an order of court of common pleas after application demonstrating good causefor disclosure.Community Care Staff Having Knowledge of, or Having, a Relationship with theMemberCommunity Care will ensure that no conflicts of interest exist between Community Carestaff in/when dealing with member treatment decisionsA Community Care staff member that has any independent knowledge of, or arelationship with, the member for whom he/she is making coverage decisions, shalldisclose that knowledge or relationship to his/her supervisor. The supervisor will decideon the appropriate process for making decisions for that member.Confidentiality and Privacy Training for Community Care StaffTraining on confidentiality and privacy regarding member information and utilizationrecords for Community Care staff will be conducted at hire and annually thereafter, withany change in job title/duties, or when significant changes in laws or policies regardingconfidentiality warrant retraining. This training will be intended to provide CommunityCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 166

Care personnel with guidance concerning the disclosure of information related tomembers, providers, services furnished to members, or other confidential information.The training sessions are designed to ensure understanding and adherence to allfederal and state regulations related to confidentiality and member rights.Learning Objectives of training sessions are: To define and demonstrate the importance of confidentiality of Protected HealthInformation (PHI) within the MCO setting. To ensure confidentiality of all sensitive organization or member information. To review IS security controls (user ID and Password) that protect memberidentifiable information. To learn how to verify the identity of a person requesting PHI. To identify areas where confidentiality may be an issues, e.g., telephone; writtenmaterials; public discussion, staff workstations, computer files and databases.Methods used during training sessions include:Online training session and exam.Signed confidentiality agreement (at hire).Resources used during training sessions include:Statements of Confidentiality (Attached).CPL 032 and CPL 033, Confidentiality policies and procedures.State and federal statues and regulation.Director of compliance.Privacy officer.Compliance Department.Persons Responsible for participating in training sessions include:All Community Care staff members participate in the training sessions.Staff shall be trained:Upon hiring.Annually.With any change in job title (if appropriate).Topics for training session include:Information storage and retrieval.Record retention.Access to records.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 167

Confidentiality policies pursuant to all relevant state and federal regulations incompliance with CPL 032 policy sections listed below:• General Confidentiality Provisions.• Oversight of Confidentiality.• Collecting and Using Member Identifiable Information.• Handling of Member Identifiable Information.• Informing Members about Confidentiality.• Ability to Give Informed Authorization.• Member Access to Utilization Records.• Disclosure of Information.• Disclosure of Information to Employers.• Handling of Practitioner Specific Information.• Informing Providers About Confidentiality.• Practitioner Office Confidentiality.• Handling of Community Care’s Business Information.• Subpoenas.• A member’s right to amend PHI.• A member’s right to an accounting of disclosures of PHI.Confidentiality policies pursuant to all relevant state and federal regulations incompliance with CPL 033 policy sections listed below:• Confidentiality: Terms and Disclosure Policy• Confidentiality: Compliance With State and Federal Laws• Notice to Accompany Information Released Pursuant to Written Authorization forDisclosure• Release of HIV-Related Information• Release of Information Related to Treatment of Minors• Release of Information Related to Treatment of Mental Health• Release of Information Related to Drug and Alcohol Dependency and Treatment• Community Care Staff Having Knowledge of or a Relationship with the Member• Confidentiality and Privacy Training for Community Care StaffThe Notice of Privacy Practices for PHI include:• Safeguarding the Member’s Information.• Disclosure of Information for the purposes of Treatment, Payment and HealthCare Operations.• Disclosures of Information:• When required by law.• For public health activities.• Health oversight activities.• Lawsuits and disputes.• Law enforcement.• Coroners, medical examiners, funeral directors, and organ donation.• Research purposes.• Serious threats.• National security and intelligence activities.• Protective services for the President and others.• Military and veterans.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 168

• Workers compensation.• Inmates.• Disclosures of Information in which the member’s signature is required• The member’s Rights Regarding PHI:• To request restrictions on the uses and disclosures of their PHI.• The right to choose how Community Care will contact them.• The right to inspect and copy PHI.• The right to request an amendment of their PHI.• The right to an accounting of disclosure.• The right to obtain a copy of this notice.• Privacy Notice.• How the member receives a copy of changes made to the Privacy Notice.• How the member may file a complaint about our Privacy Practices.• How the member may have questions or concerns regarding privacy or theNotice of Privacy addressed.• The effective date for the Notice of Privacy.• Reporting inappropriate use of member information.• Non-Retaliation Policy.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 169

“Statement of Confidentiality” AgreementMember and Provider InformationI understand and agree that in the performance of the specific assigned duties forCommunity Care, I must maintain and safeguard the confidentiality of all personallyidentifiable member, practitioner, or provider information. This information must be keptstrictly confidential and must never be disclosed, other than for appropriate businesspurposes, and only to those persons who need to know.General InformationI understand that, in addition to the foregoing, there is a wide range of other sensitiveproprietary and business information including, but not limited to, Community Careplans and projects; financial and operating details; prospective and past transactionswith customers, suppliers and other companies; and compilations of business data. Iunderstand that every precaution should be exercised to preserve the confidentiality ofall such information until specifically released in writing or made public by CommunityCare officials.Because of my affiliation with Community Care, I know that I have access to sensitiveand confidential data and information and by signing this Statement I agree not toaccess data and information from source (s) that are not needed to perform my jobduties.I expressly agree that I will not use information for my own benefit nor disclose it toothers, except as properly authorized and for appropriate business purposes.I also agree that when my work with Community Care is ended for any reason, I willpromptly deliver to Community Care all correspondence, reports, memoranda, records,manuals, notes, drawings, data, software, and other materials belonging to CommunityCare and pertaining to its business, including copies of any of the foregoing materials,which may be in my possession or under my control.When faced with an inquiry from an outside source, whether at work or away from work,or whenever I have any doubts about disclosure of information, I agree that I willdisclose nothing and ask my Director/Supervisor or the Privacy Officer at CommunityCare for direction.Signature/DateWitness/DateCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 170

POLICYCommunity Care, our staff and agents, shall protect the confidentiality of all confidentialdata and information to which they have access. “Confidential” information is defined asany information by which the member could be identified. The purpose of this policy isto assure that all data and information obtained by Community Care, and ourrepresentatives, are maintained and used with the degree of confidentiality and securitythat the data and information warrant.PROCEDUREGeneral Confidentiality ProvisionsCommunity Care has designated the privacy officer to oversee company policies andprocedures regarding confidentiality and privacy. The specific functions for which theprivacy officer is responsible include but are not limited to:Annual review of all confidentiality policies.Annual training of Community Care employees on confidentiality.Follow-up to concerns of members or providers regarding confidentiality.The Compliance Department will assist the privacy officer with these responsibilities asrequired and requested.Community Care employees, staff, and volunteers are required to sign CommunityCare’s “Statement of Confidentiality” agreeing to be bound by strict confidentialitypolicies and procedures, including all federal and state laws, and the Health InsurancePortability and Accountability Act of 1996 (HIPAA). Signed “Statements ofConfidentiality” are maintained by Community Care’s Compliance Department.Community Care business associates potentially having access to confidentialinformation are required to sign Community Care’s “Statement of Confidentiality”agreeing to be bound by Community Care’s strict confidentiality policies and proceduresor must conform to equivalent provisions as determined by Community Care staff orlegal counsel.Breach of the “Statement of Confidentiality” or equivalent is grounds forimmediate termination.When Community Care becomes aware of a breach in confidentiality:The privacy officer will alert senior management of the breach.An investigation regarding the breach of the member’s (or provider’s) confidentialitywill be conducted by, or under the direction of, the privacy officer.All necessary staff will be interviewed.Any physical material involved will be reviewed.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 171

Findings will be reported to senior management.If applicable, Community Care will alert the Secretary of Health and HumanServices, and any other state or federal government agencies, and the physicalhealth plan when necessary, of the breach in confidentiality.At times, Community Care may have interns, residents, or students who may beexposed to member protected health information (PHI) during his/her rotation. They arerequired to sign Community Care’s “Statement of Confidentiality” in the beginning oftheir rotation and review all confidentiality policies and procedures.Education related to the principles and procedures for maintaining confidentiality isrequired for all Community Care employees, staff, and volunteers at the time of hire andannually thereafter. When an employee, staff, or volunteer has a significant change inhis/her job title or assignments, his/her director/supervisor will review all confidentialitypolicies that pertain to his/her new assignments at the time of the transition.Documentation of confidentiality training will be maintained in the employee’s personnelfile located in Human Resources Department (HIPAA Section 164.530(b)(1)).Community Care considers the following data and information to be confidential:Member identifiable data and information: that is, all data and information where themember is, or could possibly be, identified.Explicitly identifiable data include, but are not limited to, member name, SocialSecurity Number, medical record number, health plan beneficiary numbers, accountnumbers, certificate/license numbers, or other identifier that can be directly linked toa specific individual.Implicitly identifiable data include, but are not limited to, member address, telephonenumber, fax numbers, electronic email addresses, date of birth or other suchinformation that, alone or in combination with other available information, can lead toidentification of a specific individual.Practitioner specific data and information, including but not limited to, that used fornetwork development, credentialing, performance evaluation, quality assurance,quality improvement, and peer review.A practitioner’s name, professional degree, status as a member of CommunityCare’s practitioner network, business address, business telephone number, andspecialty/specialties or self-identified areas of special interest are not consideredconfidential when disclosed for legitimate business purposes.Data and information related to a practitioner’s racial, cultural or ethnic background,age, religious affiliation, sexual orientation, and ability to communicate in languagesother than English, is confidential unless the practitioner explicitly authorizes therelease of this information.Practice/group specific and facility specific data and information, including that it isused for but not limited to, network development, organizational assessment andcontracting, performance evaluation, quality assurance, and quality improvement.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 172

A facility or group practice name, status as a participant in Community Care’snetwork, business address, business telephone number, and services offered arenot considered confidential when disclosed for legitimate business purposes.Community Care’s business data and information considered confidential includes but isnot limited to:Salaries.Policies and procedures.Finances.Business plans.Practitioner, practitioner group, and facility participants in Community Care’s networkwhen such information is not being released for legitimate business purposes.Proposals to potential or current customers.Information disclosed to Community Care in confidence by a third party.Information including quality assurance, quality improvement and performanceevaluation data and information where practitioners, practitioner groups, or facilitiesare not individually identifiable.Community Care has an array of security provisions to protect confidential data andinformation, including:Differential access based on job responsibilities to information maintained inCommunity Care’s information system.Physical lock and key arrangements.Electronic security systems.Mandatory compliance with Community Care’s Statement of Confidentiality.The following provisions are in effect for all Community Care representatives:Divulging computer passwords and security system pass codes is prohibited.Building access codes and keys may not be shared with any individual who does nothave the right to such access codes or keys.All computers that have the ability to access confidential data or information mustbe:• Protected with a confidential log-in password.• Turned or logged off at the end of the workday.• Protected with a confidential screen-saver password in the event that thecomputer is turned on and logged on while the computer user is away fromhis/her work area.Community Care’s agents, contractors, employees, staff, and volunteers may notaccess or view confidential data or information unless required by his/her duties orresponsibilities for, or on behalf of, Community Care. The “Statement of Confidentiality”includes a statement that an employee has access to sensitive and confidentialCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 173

information and by signing this statement he/she agrees not to access information fromany source (s) that is not needed to perform his/her job duties.Another part of the “Statement of Confidentiality” is that only the minimum necessaryinformation is used by any employee at Community Care to perform his/her job duties.Community Care’s expectations are that only the minimum amount of informationneeded by our employees is used.Community Care’s Compliance and IS Departments oversee and monitor employeeaccess to member confidential data. Community Care’s agents, contractors, employees,staff, and volunteers may not discuss confidential data and information in an area whereindividuals, including other Community Care agents, contractors, employees, staff, andvolunteers who do not have the right to know about the information, may overhear theinformation.All confidential data and information must be maintained in a manner that preventsaccess by individuals who do not have a right to access the data and information.All physical media, including but not limited to paper, magnetic, and optical, used tostore confidential data and information must be stored under a double lock system.All physical media containing confidential information that are still in use byCommunity Care agents, contractors, employees, staff, and volunteers at the end ofthe day must be locked in that individual’s desk or in another secured storage area.All desks or secured storage areas must be in areas with keyed entry, maintaining aminimum of a dual-key system.All physical media containing confidential information that are no longer needed byCommunity Care agents, contractors, employees, staff and volunteers must bereturned to locked master storage at the end of the day.All electronic media containing confidential information must be password protected.The transfer of confidential information for legitimate business purposes betweenCommunity Care’s agents, contractors, employees, staff, and volunteers in his/herofficial capacities as representatives of Community Care, is considered an internaltransfer, even though they may be in different physical locations. The data they receivemay be decoded or “aggregate data” to protect the members’ health information.The internal transfer of all confidential data and information must be conducted in amanner that limits potential access by individuals who do not have a right to access thedata and information. Each director will determine the specific access and confidentialinformation his/her employees will need to access, in order for them to carry out his/herjob duties (HIPAA Section 164.504(f)(2)(iii).When not hand-carried and personally delivered to the recipient, physical mediacontaining confidential data and information must be placed in a sealed envelopemarked “confidential.” Confidential data and information sent by facsimile must beara prominent confidentiality notice similar to the following: “This facsimiletransmission contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you areCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 174

the intended recipient. If you believe you have received this message in error,please notify the sender by facsimile or telephone and destroy this document.”Confidential data and information sent by email must be flagged as confidential andbear a confidentiality notice similar to the following at the beginning of the message:“This email contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this email in error, pleasenotify the sender by return email, securely delete this file, and any electronic ormagnetic copies, and destroy any paper copies.”Protected health information will not be transmitted via email.Confidential data and information no longer required for legitimate businesspurposes must be destroyed in a secure manner.Paper records must be thoroughly shredded.Magnetic files must be deleted in a manner that does not permit the files to beundeleted; for example, by reformatting a floppy disk using the “secure” formatoption.Optical storage media must either have the files securely deleted or, if this is notpossible, the storage media must be destroyed.If the receiver does not have the necessary means to destroy this information, theymust return the information back to Community Care in order for it to be destroyed.The transfer of confidential information other than to Community Care’s agents,contractors, employees, staff, and volunteers in his/her official capacities asrepresentatives of Community Care is considered an external transfer and must bemade in accordance with Community Care’s procedure on Disclosure of Information.Oversight of Confidentiality PracticesCommunity Care’s privacy officer is responsible for:Approving and annually reviewing all policies and procedures related toconfidentiality.Identifying, developing and implementing mechanisms to oversee theimplementation and application of Community Care’s confidentiality policies andprocedures.At least annually, the privacy officer, in collaboration with the Compliance Department,will evaluate ways to:Reduce the collection of member identifiable data and information.Aggregate or de-identify (the process of separating medical information frompersonal identification such as, removing a name or Social Security Number in orderto prevent the identification of a specific member) such data and information asclose to the collection point as possible by surveying Community Carerepresentatives, conducting focus groups with Community Care representatives, andreviewing complaints.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 175

Community Care has identified circumstances necessitating special protection ofMember-identifiable data and information as described in the procedure on Handling ofMember Identifiable Information. Community Care acknowledges that additionalcircumstances necessitating such special protection may also arise (HIPAA 164.522).All requests for special protection of Member-identifiable data and information notaddressed in the policy referenced above shall be referred to the Privacy Officer.The privacy officer will consider the request and determine whether the requestshould or should not be honored.If the privacy officer determines that the request should be honored he/she will sendthe member a letter within 30 days including:• Notify the requestor of his/her decision.• Determine the mechanism to adhere to the request.• Update the procedure on Internal Handling of Member Identifiable information toreflect the addition.If the privacy officer determines that the request should not be honored he/she willsend the member a letter including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.• The name, or title, and the telephone number of the contact person for the nextstep.All member and practitioner concerns regarding confidentiality shall be logged ascomplaints and processed through Community Care’s complaint and appeals process(HIPAA Section 164.530(a)(1)(ii)).The privacy officer will be notified by the Complaint and Grievance Departmentabout complaints regarding privacy or confidentiality.The privacy officer or his/her designee will maintain a log with all complaints orgrievances dealing with confidentiality and privacy.The privacy officer or his/her designee will work with the Complaint and GrievanceDepartment on resolving complaints dealing with confidentiality and privacy.The privacy officer is responsible for reviewing requests for access to memberidentifiable data and information from all sources (internal, external, and businessassociates) and may enlist the cooperation of the Compliance Department andmedical director as appropriate.In determining the time frame within which to conduct such a review, the privacy officeror medical director if appropriate, will consider the potential benefit to the membershipfrom the requested access to data and information. For example, health outcomes maybe improved if access is granted to information on diagnosis so that a healthmanagement or preventive health program can be implemented.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 176

In the event that Community Care would participate in a research study, the medicaldirector in collaboration with the privacy officer is responsible for reviewing all requeststo access confidential data associated with a research project.The medical director or his/her designee will request a description of the purpose forthe requested information from the business associate.All requests for de-identified information will be recorded in the Request for DeidentifiedInformation Log.Each request will be reviewed individually.For each request, Community Care will determine how this information will be deidentified.If Community Care is able to reduce the amount of information requested while stillmeeting a business associate’s request, it will do so.Community Care will develop a code to de-identify this information (HIPAA164.514(c). This code will be unique with each request for information. This code willnot be released to the business associate, and each code will be kept in the Requestfor De-identified Information Log. Only the medical director or his/her designee willhave access to this log.The medical director will present the request for information to the OutcomesCommittee for final approval.When the privacy officer receives the decision from the Outcomes Committee; theywill notify the requestor in writing, confirming if the requested information will bereleased, the manner in which it will be released, and how the information will be deidentified.If Community Care did not grant the request for information, a briefexplanation of the reason will be given instead.Once this has all occurred, the member will be contacted by Community Care to seeif he/she would like to participate in any active clinical research activity. CommunityCare is required to receive the member’s authorization prior to the release of anyinformation to a business associate for research purposes. If the member agrees toparticipate in the study and once the signed authorization is received from themember, the information will be released to the business associate conducting theresearch.If the member declines to take part of this study, his/her coverage will not beterminated with his/her refusal to participate.Collecting and Using Member Identifiable InformationCommunity Care collects and uses only the minimum necessary member identifiabledata and information routinely in the performance of our work. Community Careemployees are required to sign a “Statement of Confidentiality” when hired, agreeing tobe bound by Community Care’s strict confidentiality policies and procedures and allfederal and state laws.Community Care considers the following as member identifiable information, but it is notlimited to that listed below. This information used alone or in any combination mayidentify the member (HIPAA 164.512(b)(2)(I)):Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 177

NameAddress (es)Zip CodeDiagnosis (es)Treatment DatesDate of BirthDate of DeathTelephone Number (s)Fax NumberElectronic Mail AddressSocial Security NumberUtilization Record ID NumberHealth Plan Beneficiary Number (s)Account Number (s)Certificate/License NumberDriver’s License NumberWeb Universal Resource Locators (URL’s)Any unique identifying number, characteristic, or code in which Community Carecreated that if external sources deciphered the code they could identify the Member.There are times when disclosures of protected health information are made on a routineand recurring basis, to providers for the purposes of treatment, payment, and healthcare operations (HIPAA Section 164.514(d) (3)). These disclosures are a vital part ofour daily performance and may not be restricted. The provider identification is verifiedby our caller ID system as well as by the provider supplying specific identifyinginformation pertaining to the member, e.g., member ID and Social Security Number.Community Care staff identifies themselves to providers with their names, titles, andspecific identifying information pertaining to the member. If at any time there is aquestion as to the identity of the caller, staff members are instructed to take the name ofthe caller, the facility that is calling, and a telephone number where the call can bereturned. The contact and telephone number are verified before the call back is madeand any information is divulged.While Community Care does not maintain a medical record, Community Care doeskeep a utilization record. Per HIPAA (Section 164.501) a designated record set whichCommunity Care refers to as a utilization record is – a group of records maintained byor for Community Care, used, in whole or in part, by Community Care to make decisionsabout the member or provider, which may contain the following but is not limited to:The medical and billing records about the member or provider.The enrollment, payment, claims adjudication, and case or medical managementrecord systems maintained by Community Care.In accordance with HIPAA (Section 164.524), the member may request to restrict thisinformation if desired. The member has the right to request at any time to restrict theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 178

collection, use, or disclosure of his/her protected health information. The member maywrite a letter to the privacy officer at Community Care, requesting to restrict thedisclosure of his/her protected health information. The letter must include what specificinformation the member wants restricted, the member’s signature, and it must be dated.The privacy officer will review the member’s request and will respond in 30 days inwriting if this information is on site. If the information that the member is requesting isnot on-site, Community Care will retrieve the information within 60 days.If needed, Community Care may extend the retrieval an additional 30 days provided thatthe member is sent a written letter with an explanation for the delay, and provide a datein which we will have this information. Community Care will only have one suchextension of time for each request. If the restriction of protected health is granted:The privacy officer will send a letter to the member informing him/her howCommunity Care will limit his/her information.The privacy officer will oversee the process to restrict the PHI.This granted request for restriction of PHI will be recorded in the Member Request toLimit Protected Health Information Log, which is maintained by the privacy officer orhis/her designee.The privacy officer will notify the manager of the file room to have the member’s filepulled.The privacy officer or his/her designee will place on the front of the member’sutilization record a sticker.The sticker will have in writing on it “RESTRICTED INFORMATION.”If this file is requested by an employee, the file room clerk must see the privacyofficer, or his/her designee, to receive permission to process the request this file.Once the employee is finished with this file and returns it to the file room, the fileclerk must alert the privacy officer or his/her designee that the file has beenreturned.The privacy officer will notify all necessary department managers of the member’srequest to limit his/her PHI.PsychConsult will contain an alert notifying staff that this particular member’srecords are restricted.If the Member’s request is denied the privacy officer will:Record in the Member Request to Limit Protected Health Information Log that therequest was denied.Send the member a letter within 30 days of the decision including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.• The name, or title, and the telephone number of the contact person for the nextstep.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 179

Community Care has the right to deny any request made by the member:That will interrupt daily operations to carry out treatment, payment, and health careoperations.If there is information subjected to the Clinical Laboratory ImprovementsAmendment of 1988, 42 U.S.C. 263a, to the extent the provision of access to theindividual would be prohibited by law: or Exempt from the Clinical LaboratoryImprovements Amendment of 1988, pursuant to 42 CFR 493.3(a)(2) (HIPAA164.524).If the information was compiled for a civil, criminal, or administrative action orproceeding.If the information involves the member currently in a correctional institution.If the member’s records are subject to the Privacy Act, 5 U.S.C. 552a, the membermay be denied the right to restrict or limit the use of his/her information under thisact.The member has the right to have his/her denial reviewed by a licensed health careprofessional who was not part of the original decision to deny. The member must write aletter to Community Care’s privacy officer requesting that his/her denial be reviewed.Community Care has designated our medical director to be the licensed health careprofessional to review this request. Community Care’s medical director must determinein a reasonable time, whether or not to grant or deny the member’s access requestbased on the above. A letter must be sent to the member with the medical director’sdecision.If the medical director’s decision is to grant the member’s request to the restriction thenproceed as above. If the opinion of the medical director is still to deny the request, aletter with this decision must be sent to the member including the reason for the denial,and an explanation of Community Care’s complaint and grievance process, includingthe name, or title, and the telephone number of the contact person for the next step.At any time the member may lift the restriction of his/her PHI by writing a letter toCommunity Care’s privacy officer requesting the restriction be lifted. Community Careprovides to members the Notice of Privacy, which describes the uses and disclosures ofPHI. The Notice of Privacy is sent to all members.Community Care uses the following methods to notify subscribers of Community Care’sroutine collection and use of member identifiable information:When Community Care is responsible for managing the enrollment process,subscribers are notified in writing at the time of enrollment of Community Care’sroutine collection and use of member identifiable information.In most instances, Community Care is not responsible for managing the enrollmentprocess. To ensure that all subscribers are notified of Community Care’s routinecollection and use of member identifiable information, some of the followingmechanisms are used:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 180

The health plan may distribute the information to its members.Members may be notified in Community Care’s Member’s Handbook or via membernewsletters that are mailed throughout the year with updated information.Members may request to have this information sent to a different address or locationthen where they are currently residing. They may write a letter to the privacy officerat Community Care or call member services and inform us as to where they wouldlike the information sent (HIPAA 164.522(b)).A Notice of Privacy authorizing uses of member identifiable information is posted onCommunity Care’s website and members are informed of this posting via printedmaterials such as newsletters with a note that Community Care will provide theNotice of Privacy in written form upon request.Whatever the communication mechanism, the following language, or equivalent, is usedto notify subscribers of Community Care’s routine collection and use of memberidentifiable information: “Community Care uses information about you and yourdependents (if applicable) to enable us to verify eligibility for services; authorizetreatment; pay claims; coordinate care; resolve inquiries, complaints, and appeals;improve the care and service rendered by Community Care and its network ofPractitioners and Facilities; and meet regulatory requirements and accreditationstandards. If we use information for reasons other than those described above, we willremove any portions of the information that could allow someone to identify you or yourdependent, or we will contact you or your dependent to ask for written authorization touse the information.”Community Care does not disclose PHI for underwriting purposes.Handling of Member Identifiable InformationAll data and information where the member or subscriber is, or could possibly be,identified are confidential. An individual’s status as the member or subscriber isconsidered confidential member identifiable information.A treatment record is a confidential document that is the record of privilegedcommunication between a consumer and a health care practitioner or facility.Community Care may obtain copies of treatment records for legitimate businesspurposes.Member identifiable information may not be divulged by telephone without firstverifying the identity of the other party.A case number or Social Security Number and date of birth may be used to verifythe identity of an individual claiming to be a member or subscriber.If there is suspicion about the identity of an individual, even when such person cansupply a correct case number or Social Security Number and date of birth, theCommunity Care representative should seek additional verification or requestassistance from a supervisor or manager.The member requesting information about his or her treatment should be referred tothe treating practitioner.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 181

Member identifiable information may not be disclosed to the member’s relatives orfriends except as described in the Disclosure of Information policy and procedure.Data and information derived from treatment records, utilization management records,or other clinical sources shall not be considered confidential if they are de-identified orcombined and aggregated with other data and information in a manner that precludesthe identification of specific members. When considering the adequacy of suchaggregation or de-identification to maintain the members’ confidentiality, the CommunityCare representative disclosing the data or information must consider what other data orinformation may be available to the recipient that could enable the recipient of theinformation to identify specific members.Members have the right to request special limits on access to member identifiableinformation. For example, the member who is also an employee of Community Caremay request that information on his or her treatment be afforded special protection.The following table describes circumstances that Community Care has determinedcreate a right to special protection of member identifiable data and information and themechanism that Community Care has implemented to adhere to the request:Reason for Special Protection ofProtected Health InformationThe subscriber is a staffmember/employee (or a familymember) or volunteer at CommunityCareMechanism to Adhere to RequestNo clinical information is maintained inCommunity Care’s information systemother than routine eligibility dataClinical reviews are conducted by themedical director, designatedprofessional advisor, or Chief ClinicalOfficerClaims adjudication is handledmanually by the department supervisorInforming Members about ConfidentialityCommunity Care prepares information, written at a 4 th grade reading level, for membersthat describes Community Care’s confidentiality policies and procedures. Theinformation covers the following topics:Collecting and using member identifiable information, including provisions for routinenotification of the collection and use of member identifiable data and information.Use of authorizations and ability to give informed authorization.Access to protected health information.Internal protection of protected health information across the organization.Member access to protected health information.Disclosure of Information.Protection of information disclosed to plan sponsors or employers.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 182

A member’s Right to Amend Protected Health Information.A member’s Right to an Accounting of Disclosures of Protected Health Information.If the member feels that his/her protected health information has been released or usedinappropriately, they have the right to file a complaint. They may either file the complaintby calling member services or writing a letter to Community Care’s Complaint andGrievance Department. They may also file a complaint with the Secretary of Health andHuman Services who oversees the HIPPA regulations.As part of the HIPAA regulations, members are notified via a Privacy Notice ofCommunity Care’s privacy policies and how Community Care limits and protects PHI.The Privacy Notice is sent to all members detailing our privacy policies and how we willmaintain their confidentiality. Changes made to the Privacy Notice or policies dealingwith privacy and confidentiality will be sent to members. Notification will be through themember updates/alerts including a description detailing the change (s) and when thechange (s) will occur. Community Care will give members a 60-day notice prior to thechange (s) becoming effective.Ability to Give Informed AuthorizationCommunity Care obtains special authorization to release member identifiableinformation as described in the Disclosure of Information policy and procedure.Community Care considers the following individuals capable of giving validauthorization for the release of member identifiable health information:The member, who has reached the age of majority as identified by CommunityCare’s eligibility data is capable of giving informed authorization on his or her ownbehalf unless Community Care has received notification that the individual has beenadjudicated incompetent.The legal guardian, natural or adoptive parent of a minor, as identified in CommunityCare’s eligibility data is capable of giving informed authorization on behalf of theminor unless Community Care has been informed that the parent has beenadjudicated incompetent, is not the legal guardian, or the minor has been legallyemancipated.An emancipated minor is capable of giving informed authorization on his or her ownbehalf. If not already on file with Community Care, Community Care will requestproof of the minor’s status from the minor before honoring the authorization.A legally authorized representative is capable of giving informed authorization onbehalf of the individual he or she represents. Community Care requires written proofof the individual’s status as legally authorized representative and that the statuscovers the area for which the authorization is being sought.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 183

Community Care extends all reasonable effort to develop and maintain anaccurate and efficient system for member information.Having established such a system, Community Care reasonably relies on theabsence of information indicating that the member or parent of a minor has beenadjudicated incompetent and that a parent is not a minor’s legal representative.Verifying the accuracy of the absence of such information would place an undueburden on Community Care and in most instances would require a breach ofconfidentiality.When Community Care is informed that the member is unable to give specialauthorization for the release of information, Community Care will acceptauthorization from, and/or release records to, a representative legally authorizedto release or receive the member’s personal health information. CommunityCare requires written proof of the individual’s status as a legally authorizedrepresentative and that the status covers the area for which the authorization isbeing sought.Individuals capable of giving valid authorization for the release of memberidentifiable health information are also entitled to have access to suchinformation except as follows: parents or guardians of children age 14 years orover may not have access to the child’s health information without authorizationfrom the child.Member Access to Utilization Records/Protected Health InformationCommunity Care does not provide direct care or treatment to members.In the event that Community Care intends to become a direct provider of careand treatment, Community Care will develop policies and procedures thataddress:How members can access their medical records if permitted.A process whereby members may restrict, access, amend, or have an accounting oftheir medical files that are under Community Care’s control.In accordance with HIPAA (Section 164.524), the member may access his/herutilization record if desired. The member may request to view his/her utilizationrecord by writing a letter to the privacy officer at Community Care.The privacy officer reviews the member’s request and will respond within 30 days.If the information requested by the member is not on site, Community Care willretrieve the information within 60 days.If needed Community Care may extend the retrieval an additional 30 days providedthat the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for the request.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 184

If a member is granted access to review his/her records:The privacy officer will oversee the process to view the PHI.This granted request to review records will be recorded in the Member Request toReview Protected Health Information Log, which will be maintained by the privacyofficer or his/her designee.The privacy officer and or his/her designee will discuss with the member:• The format in which this information will be presented• How and where this information will be viewed (the member may choose toreview his/her records at Community Care or have the information mailed in anenvelope marked confidential to an address that they have specified).• If the member would like a summary of the information, or copies.• That a nominal fee may be charged by Community Care for postage, copying, orpreparation of the information (including the labor of copying the informationrequested).If Community Care is unable to accommodate the member’s request to view thisinformation, the Privacy Officer will send the member a letter describing:The decision.The reason for the denial.A description of the appeals process.The right to file an appeal along with the process for filing.The name, or title, and the telephone number of the contact person for the next step.Disclosure of InformationExcept as described in the procedures in Collecting and Using Member IdentifiableInformation, Community Care requests authorization from the member or the member’slegally authorized representative prior to disclosing the member’s PHI to externalsources.Community Care will only disclose PHI in accordance with the most restrictiveconsent, authorization or other written legal permission from the member, unlessotherwise specified by the member (HIPAA 164.506(e)).The member or the member’s legally authorized representative has the right to denythe request to release member identifiable information without any consequences tothe member or the member’s coverage.If member identifiable data and information are to be disclosed for purposes other thanthose described in the policies cited in paragraph 1, above, the authorization of themember or member’s legally authorized representative is required (HIPAA Section164.504). This includes, but is not limited to information:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 185

For research purposes.On behavioral health signs, symptoms, diagnoses, or treatment from a primary carephysician or other clinician not providing behavioral health care.That could result in a member being contacted by another organization for marketingpurposes.There may be times when Community Care needs to disclose information about themember without receiving informed authorization. These situations include, but arenot limited to (HIPAA Section 164.506(a) (3) (I)):Emergency situations where the member’s life or other lives may be at risk.Community Care may disclose information for the purpose of identification andlocation of the member with or without his/her authorization in response to a lawenforcement official’s request for information to identify, or locate a suspect, fugitive,material witness, or missing person. The following information may be releasedunder these circumstances (HIPAA 164.512(f)(2)):• Name and address.• Date and place of birth.• Social Security Number.• Date and time of treatment.• Date and time of death, if applicable.• Any description of distinguishing physical characteristics (height, weight, gender,race, hair/eye color, and any distinguishing traits - scars, tattoos, etc).When there is a substantial barrier to communication with the member andCommunity Care’s representative, using his/her professional judgment, believes theindividual’s consent to receive treatment is clearly inferred.When authorized by Community Care’s legal counsel to meet the requirements offederal, state, and local law.For public health activities as required by law (HIPAA 164.512(b)(i)):• To prevent or control disease, injury, or disability.• To report births and deaths.• To report child abuse or neglect.• To report reactions to medications or problems with products.• To notify people of product recalls, repairs, or replacements.• To notify a person who may have been exposed to a disease or condition.• To notify the appropriate government authority if we believe the member hasbeen the victim of abuse, neglect, or domestic violence.• Disclosures to federal, state, or county agencies that oversee Community Care,such as governmental monitoring of the health care system, medical assistance,government programs, and compliance with civil rights laws.• In regards to the care or payment related to the member’s health care (HIPAASection 164.510(b)).Under some circumstances, it may be necessary to obtain authorization verbally. Theuse of a verbal authorization should be approved in advance by Community Care’s legalcounsel or, if circumstances indicate a need for a rapid decision then by a member ofCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 186

Community Care’s senior management team. If approved, two representatives ofCommunity Care must witness the entire process of obtaining verbal authorization torelease information.Community Care considers an authorization to release information to be valid only if(HIPAA 164.508(c)) :It provides the name of the person(s) providing the information.It is in a language the member can understand.There is a purpose for the release.The specific information to be released (dates of treatment, and the exact type ofinformation to be released, i.e., mental health, drug and alcohol) is described.The member’s full name at the time of treatment and correct identifying information,e.g., date of birth and Social Security Number.The individual or entity authorized to receive the information is described.The expiration date of the authorization.The signature of the member or the member’s legally authorized representative (ifthe authorization is signed by a personal representative of the individual, adescription of such representative’s authority to act for the individual).The release is obtained in a manner that complies with applicable law andregulations.There is a statement that treatment will not be affected if the member or member’srepresentative refuses to sign the authorization.There is a witness signature.There is a date of expiration for the authorization.There is a written statement on the authorization form that once this information isreleased to the recipient, this information may be subjected to re-disclosure by therecipient and no longer protected by this rule.There is a statement on the authorization form that if this information is used ordisclosed pursuant to the authorization, it may be subject to re-disclosure by therecipient and no longer be protected by this rule.There is a statement that the individual has the right to revoke this authorization inwriting, including the exceptions to the right to revoke, and a description of theprocess for the individual to revoke the authorization.Community Care will not release the information unless the form is completed.Prior to releasing information of previously signed authorization to releaseinformation, Community Care will review all authorization forms that are still in effectto ensure that they are compliant with HIPAA regulations.If a previously signed authorization is compliant with HIPAA regulations CommunityCare will continue to release the information until the authorization expires.If the authorization is not HIPAA compliant, then Community Care will contact themember within 60 days to obtain a newly signed authorization that conforms toHIPAA regulations.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 187

See the policy on Transition of Prior Consents and Authorizations for the completeprocedure.Community Care may use and disclose PHI in order to improve business operationsand services to members. PHI that has been de-identified and restricted may bereleased to business associates for activities such as, but not limited to: oversight,auditing, or improving Community Care’s daily operations (HIPAA 164.504(f)(2)). Priorto releasing such information, business associates must sign a Business AssociateAgreement. This agreement holds the business associate accountable for the PHI thatthey will receive. Included in the agreement is (HIPAA Section 164.512(i)):A description of the permitted uses and disclosures of the limited PHI by therecipient, consistent with the purposes outlined in his/her proposal or contract.The requirement to limit access to who may receive the data.The requirement that the business associate will not use or disclose this informationother than as permitted by the agreement or otherwise required by law.The requirement that the business associate will take appropriate safeguards toprevent the use or disclosure of the information. If the business associate becomesaware that the information was tampered with or released mistakenly they mustnotify Community Care. Community Care will give the business associate anopportunity to investigate and rectify the situation.The requirement that the business associate will ensure that any agents, including asubcontractor, to whom the business associate provides the limited information,agrees to the same restrictions and conditions that apply to the business associate.The expectation that the business associate will not try to re-identify the informationor contact members.An explanation that if the Secretary of Health and Human Services requests thisinformation in order to oversee if Community Care is compliant with HIPAAregulations, the business associate will release the information to the Secretary.The requirement that, once the information is no longer needed the businessassociate will destroy it or return it to Community Care in order for it to be destroyed.A clause allowing the business associate contract to be terminated at any time ifCommunity Care has reason to believe that the business associate has violated anyof the above.Community Care may disclose PHI that has been de-identified to business associatesfor business functions that have been contracted. Community Care requires thefollowing of the business associate contract (HIPAA Section 164.504(e)(ii)):The information given to them will not be used or further disclosed unless it isrequired or permitted by the contract or as required by the law (HIPAA Section164.504(e)(ii)(A)).He/She will take appropriate precautions with the information they are given (HIPAASection 164.504(e)(ii)(B)).In the event that someone discloses information he/she, will report the breach toCommunity Care as soon as they become aware of it (HIPAA SectionCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 188

164.504(e)(ii)(C)).He/She will ensure any additional agents, including subcontractors to whom thisinformation may become available, follow the same restriction and conditions thatapply to him/her (HIPAA Section 164.504(e)(ii)(D)).The member may access, amend, or have an accounting of the information that isreleased to a business associate.The information released by Community Care will be available if requested by theSecretary of Health and Human Services in order to track Community Care’scompliance with HIPAA (HIPAA Section 164.504(e)(ii)(H)).At the termination of the contract or when this information is no longer needed, thebusiness associate has the necessary means to destroy this information or have thisinformation returned to Community Care in order for it to be destroyed (HIPAASection 164.504(e)(ii)(I)).A business associate’s contract may be terminated at any time if we feel thebusiness associate has violated any of the above (HIPAA Section 164.504(e)(iii)).Community Care may disclose PHI about victims of abuse, neglect, or domesticviolence without an authorization to law enforcement officials or government agenciesby a representative using his/her professional judgment (HIPAA Section164.512(c)(1)). If Community Care releases such information, it will promptly inform themember that such a report has been made except when:Informing the member would put him/her in serious danger or harm.Community Care is unable to inform the member, in which case the personalrepresentative may be informed that Community Care released this information.However, if Community Care believes the personal representative is responsible forthe abuse, neglect, or other injury then he/she would not be notified.Community Care may disclose PHI without an authorization to a law enforcementofficial:When required by law for the purposes of, but not limited to, investigating acomplaint or civil or criminal charges (HIPAA Section 164.512(f)). The informationrequested must first be forwarded to Community Care legal counsel for review.In the event that the member has died, for the purposes of alerting the law. IfCommunity Care has a suspicion that such death may have resulted from criminalconduct (HIPAA Section 164.512(f)(4)).If there is evidence of criminal conduct that has occurred on our premises (HIPAASection 164.512(f)(5)).If the member (HIPAA Section 164.512(f)(6)) contacts Community Care about acrime (commission or nature of one), the location of such crime or the victim (s) ofsuch crime; and the identity, description, and location of the perpetrator of such acrime.In this latter instance, the Community Care representative will notify his/her directsupervisor of the situation, and will call 911 to report this information.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 189

Community Care does not collect information on the following; in regards to organ andtissue donation or the deceased member’s wishes, information about decedents,information for fundraising purposes, or information for marketing purposes. In the eventthe Community Care would collect information on any of the above, an appropriatepolicy and procedure will be drafted.Disclosure of Information to EmployersCommunity Care does not share member identifiable data or information withemployers without the authorization of the subscriber, member, or member’s legallyauthorized representative and only the specific information requested will be releasedin accordance with all federal and state laws. All authorizations for the release ofinformation will be verified by Community Care prior to the information being sent. Community Care recognizes that the member or member’s legally authorizedrepresentative, and not a subscriber (unless the subscriber is also the member orthe member’s legally authorized representative) is the preferred individual fromwhom to obtain authorization to release member identifiable information to anemployer. Community Care also acknowledges, however, that current industry practice is forthe subscriber, and not each member, to sign authorization forms and otherdocuments at the time of enrollment. Requiring the signature of each member ormember’s legally authorized representative at the time of enrollment is impractical. Community Care accepts its role as an advocate of the members’ rights and willwork to effect change in the industry to increase protections for confidential memberidentifiable data and information. Community Care follows all state and federal lawsand regulations.When Community Care is responsible for managing the enrollment process,Community Care obtains authorization from a subscriber at the time of enrollment torelease the minimum member identifiable data or information to the employer.In many instances, Community Care is not responsible for managing the enrollmentprocess. If Community Care manages behavioral health benefits through an agreementwith a managed care organization (MCO), Community Care’s policy is to releasemember identifiable data or information to the MCO, knowing that in the absence of theMCO’s agreement with Community Care, the MCO itself would be responsible formanaging behavioral health benefits and would therefore have access to the memberidentifiable data or information.In any instance where Community Care must release member identifiable data orinformation to an employer, whether self-insured or fully insured, Community Caremust verify that the member has signed an authorization to release such data orinformation to the employer. Community Care will require that the employer agree inwriting to protect all member identifiable data and information from being used in anydecisions affecting the member (HIPAA 164.504(h)(3)(iv)).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 190

Many requests from employers for data and information can be fulfilled withdata and information that are not member identifiable. In instances where an employer requests member identifiable information,Community Care will inquire as to the proposed use of the data and information andattempt to meet the need with data and information that are not member identifiable,for example aggregated data or information. In instances where member identifiable data or information is required, CommunityCare will ensure that an authorization for the release of information is signed by themember prior to releasing implicit data to the member’s employer. In all instances, Community Care only discloses the minimal information necessaryto accomplish the purpose of the disclosure.Handling of Practitioner Specific InformationCommunity Care considers practitioner specific data and information, including but notlimited to, that used for network development, credentialing, performance evaluation,quality assurance, quality improvement, compliance auditing and peer reviewconfidential to the extent permitted by law.A practitioner’s name, professional degree, status as the member of CommunityCare’s practitioner network, business address, business telephone number, andspecialty (ies) or self-identified areas of special interest are not consideredconfidential when disclosed for legitimate business purposes.Data and information related to a practitioner’s racial, cultural or ethnic background,age, religious affiliation, sexual orientation, and ability to communicate in languagesother than English, is confidential unless a practitioner explicitly authorizes therelease of this information.Community Care’s credentialing and recredentialing applications request that suchinformation be supplied at the discretion of a practitioner.The credentialing and recredentialing applications state that if such information issupplied, Community Care may use and disclose only the minimum amount ofinformation to members or appropriate individuals for purposes of meeting a specificmember’s needs or requests when making referrals.Practitioner files are maintained in a locked room or locked file cabinet when not inuse by Credentialing staff or the Credentialing Committee. Practitioner files stored inelectronic, magnetic, or optical format are protected with a secure password.Access to practitioner files is limited to the network management, compliance, andcredentialing staff and the Credentialing Committee.Practitioners may review the information in their file upon request except for anyinformation from the National Practitioner Data Bank (NPDB) and peer (professionaladvisor) review information. Review of NPDB information is prohibited by federalstatute.Each practitioner is informed of the right to review information in his/her file throughthe cover letter in the application packages for initial credentialing andrecredentialing.A practitioner may obtain a copy of his/her file.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 191

The request must be in writing. Credentialing staff will send a copy of a practitioner’s file to him/her within 10business days of receipt of the written request for the file. This file when mailed willbe sealed in an envelope marked confidential. NPDB information is not included. Peer review information is not included. Practitioners are notified by the credentialing staff of any information obtained duringcredentialing or recredentialing activities that varies substantially from theinformation provided by the practitioner. Practitioners have the right to correct erroneous information. Practitioners may submit any corrections in writing or additional documents to theCredentialing Department. Credentialing staff will document any verbal information or corrections provided by apractitioner in the file including the date and signature of the individual who obtainsthe information.Informing Providers about ConfidentialityThe following policies and procedures are included in Community Care’s ProviderManual and are updated as needed: General Confidentiality Provisions. Oversight of Confidentiality Practices. Collecting and Using Member Identifiable Information. Informing Members about Confidentiality. Ability to Give Informed Authorization. Member Access to Utilization Records. Disclosure of Information. Disclosure of Information to Employers. Handling of Practitioner Specific Information. Practitioner Office Confidentiality.Practitioner Office ConfidentialityMember identifiable data and information maintained in paper based or removablecomputer storage media must be maintained under lock and key, either in lockedcabinets or in a locked area.Member identifiable data and information includes, but is not limited to, medicalrecords, appointment books, patient reminder cards, correspondence, laboratoryresults, billing records, and treatment plans whether maintained on paper, magneticdisk or tape, optical disk, or any other removable storage medium.These paper based records and removable computer storage media must be lockedexcept at times when the practitioner or another member of the office staff, who isauthorized to access treatment records, is present.When unlocked, these paper-based records and removable computer storage mediaCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 192

must be maintained in a secure location where they are not accessible tounauthorized individuals.In addition, when unlocked, these paper-based records must be maintained in amanner that their content is not visible to unauthorized individuals.Computers used to store member identifiable data or information must be protectedwith a password.Password protection is not required if all persons at the practice site are authorizedto access, for legitimate business purposes, the member identifiable data orinformation stored on the computer; and the computer is located in a secure locationnot accessible to unauthorized individuals.When a computer is used to store member identifiable data or information, themonitor is positioned such that it is not visible to unauthorized individuals.If email is used to transmit member identifiable data or information, the email isflagged as confidential and a confidentiality notice is prominently displayed at thebeginning of the email that conveys a message substantively similar to the following:“This email contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this email in error, pleasenotify the sender by return email, securely delete this file and any electronic ormagnetic copies, and destroy any paper copies.”Facsimile machines are in secured areas where faxes may not be intercepted orviewed by individuals not authorized to access member identifiable data andinformation. If facsimile machines are used to transmit Member-identifiable data orinformation, a confidentiality notice is prominently displayed on the facsimile coversheet that conveys a message substantively similar to the following: “This facsimiletransmission contains confidential and privileged information for use only by theintended recipient. Do not read, copy, or disseminate this material unless you arethe intended recipient. If you believe you have received this message in error,please notify the sender by facsimile or telephone and destroy this document.”Handling of Community Care’s Business InformationCommunity Care’s representatives and business associates may not releaseconfidential business data and information (as described in the procedure on GeneralConfidentiality Provisions) except for legitimate business purposes and within theframework of the representative’s job responsibilities or the business associate’s normalcourse of performing work for Community Care: As described in Community Care’s policies, procedures, program descriptions, andwork plans, or as authorized by a member of Community Care’s seniormanagement.All requests for confidential business information which are not explicitly addressed andauthorized by Community Care’s policies and procedures or other official documentsshould be referred to the manager of the department for documentation and follow-up.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 193

All statements to the media including press releases and interviews are made by orauthorized by Community Care’s Chief Executive Officer.SubpoenasMember identifiable data and information must not be released if a subpoena isserved without first consulting Community Care’s legal counsel.The Community Care representative receiving the subpoena should immediatelysend the subpoena, via facsimile if necessary, to Community Care’s legal counsel.If the Community Care representative receiving the subpoena is not a member ofmanagement, he or she should immediately contact his or her supervisor to act onthe matter.Legal counsel, in conjunction with appropriate Community Care staff, employees,and the treating practitioner, will determine the appropriate course of action.When the information is needed to prevent further harm to the member, CommunityCare may release PHI in response to a law enforcement official’s request with orwithout the authorization of a member who is suspected of being a victim of a crime(HIPAA Section 164.512(f)(3)).Information may be released to law enforcement officials for court proceedings or aninvestigation, after it is forwarded to Community Care’s legal counsel. CommunityCare will ensure that the proceedings and persons requesting the member’sinformation have made a good faith attempt to contact the member, or his/her legallyauthorized representative, to inform him/her that their PHI is being requested beforeit is released (HIPAA Section 164.512 (e)).If the officials are unable to locate the member and they have shown reasonable effortsin an attempt, then Community Care will release information if (HIPAA Section 164.512(e)):There is documentation to support their efforts in trying to find the member.A written notice was sent to the member’s last known address and the member wasgiven sufficient time to respond or raise objections.Once time has elapsed:• Proof that there are no objections filed by the member.• If there are any objections filed, they have been resolved through the court or anadministrative tribunal.• The information released is only to be used for the litigation or proceeding.• Once this information is no longer needed then, Community Care requires thatrequestor destroy the information, or to return it so that it can be destroyed.A Member’s Right to Amend Protected Health InformationIn accordance with HIPAA (Section 164.526), the member has the right to amendhis/her PHI if desired. The member may request to amend his/her information bywriting a letter to the privacy officer at Community Care including a reason why thisCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 194

information needs to be amended.The privacy officer will review the member’s request and will respond in writingwithin 30 days.If the information requested is not on site, then Community Care will retrieve theinformation within 60 days.If needed Community Care may extend the retrieval an additional 30 days providedthat the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for action.If the member is granted the right to amend his/her PHI then the privacy officer willoversee the process to amend the PHI.The privacy officer or his/her designee will record the granted request to amendprotected health information in the Member Request to Amend Protected HealthInformation log, which will be maintained by the privacy officer or his/her designee.The privacy officer will inform the member that the original information will remainintact. The privacy officer (or his/her designee) and the member will discuss how thisinformation will be amended. Including what type of statement will be attached to allfuture releases such as “this information, as requested by the member, wasamended.” The privacy officer will notify the manager of the file room to have themember’s chart pulled.A sticker will be placed on the front of the member’s utilization record that says:“AMENDED PROTECTED HEALTH INFORMATION.” The privacy officer or his/herdesignee will also write a brief statement to be included in the member’s file, on howthis information that was requested by the member was amended.There will be a flag in PsychConsult to inform Community Care employees that thisinformation was amended.Community Care’s privacy officer will write a formal notification alerting all thenecessary staff and providers that the member’s PHI was amended and include abrief statement on how and why.Once this process is completed the privacy officer or his/her designee will send awritten letter to the member including that his/her request to amend his/her protectedhealth information was granted, including a brief description on how it was amended.If the member is denied the right to amend his/her PHI, the privacy officer, or his/herdesignee will:Record in the Member Request to Amend Protected Health Information Log that therequest was denied.Send the member a letter including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 195

• The name, or title, and the telephone number of the contact person for the nextstep.The member has the right to request in writing that Community Care attach astatement to all future releases such as “the member requested this information beamended and Community Care denied the request.”The privacy officer or his/her designee will record in the Member Right to AmendProtected Health Information Log that the member requested a statement similar tothe one above be attached to all future releases of information.The privacy officer or his/her designee will notify the manager of the file room tohave this member’s file pulled.A sticker will be placed on the front of the member’s utilization record that says:“SEE PRIVACY OFFICER BEFORE ANY INFORMATION IS RELEASED TOOUTSIDE SOURCES.” The privacy officer will need to see the information that isrequested before it is sent to ensure that the statement that the member requestedis included with the information.The privacy officer or his/her designee will also write a brief statement to be includedin the member’s file that the member requested to amend his/her PHI was denied.The member may also request that this statement be included with all futureinformation to be released.If the information the member is requesting to be amended is not the property ofCommunity Care, the member will be referred to the originator of the documents.If the originator of the PHI is unable to act on the request (for example, a practitionerwho is no longer in practice), and Community Care’s privacy officer feels that themember’s written request is legitimate, Community Care will amend the information inour possession (HIPAA 164.526(a)(2)(i)).Right to an Accounting of Disclosures of Protected Health InformationThe member has the right to request that Community Care provide an accounting ofdisclosures of PHI made by Community Care in the 6 years (or shorter time period) priorto the date in which the accounting is requested (as per the HIPAA Section 164.528).Community Care is not required to track disclosures prior to the implementationof the HIPAA Privacy Regulations.The member has the right to request an accounting of disclosures of his/herinformation by writing a letter to the privacy officer at Community Care.The privacy officer or his/her designee will review the member request and willrespond in 30 days.If the information requested by the member is not on site, Community Care willretrieve the information within 60 days.If needed Community Care may extend the retrieval an additional 30 days provided;that the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for each request.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 196

If granted, Community Care will release to the member an accounting of his/herdisclosed PHI.The privacy officer or his/her designee will oversee the process to account fordisclosures of PHI.This granted request for an accounting of PHI will be recorded in the MemberRequest to an Accounting of Protected Health Information Log, which will bemaintained by the privacy officer or his/her designee.The privacy officer or his/her designee will notify the manager of the file room tohave the member’s chart pulled. The following will be included in the accounting ofdisclosures:• The date of the disclosure.• A brief description of the information that was released.• A statement of the purpose of the disclosure or a copy of the signedauthorization.• The name of a person or provider who requested this information (CommunityCare reserves the right to deny the request for an accounting of disclosure ofinformation if divulging the name of the person who received information could bedetrimental to the member or the person to whom the information was disclosed).• A brief statement of Community Care policy on Disclosure of Information.• If there was more than one authorized release of information during therequested time period then, the frequency, periodicity, or number of thedisclosures made is included.• If the information was for, or in anticipation of, a civil, criminal, or administrativeaction or proceeding, Community Care will not release the information.• A flag will be placed in PsychConsult to notify employees that the member askedfor an accounting of disclosures.Once this information has been compiled, the information will be mailed in anenvelope marked “Confidential” to the address that the member specifies.Each year the first request for the accounting of information is free. After this,Community Care may charge a reasonable fee for preparing the information, as long asmembers are notified.If the privacy officer determines that the request should not be honored, within 30 dayshe/she will send the member a letter including the decision; the reason for the denial; adescription of the appeals process; the process for filing an appeal; and the name/titleand phone number of the contact person for the next step.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 197

APPENDIX A.4. Significant Member IncidentsPolicyA Significant Member Incident (SMI) or sentinel event is an unexpected and undesirableoutcome that has an adverse impact on the outcome of care. The detail of each SMI ispromptly reviewed to determine needed follow-up and to coordinate communicationbetween Community Care, the provider, and county agencies, as appropriate, to avoidunnecessary duplication of reports.Community Care receives information about SMIs in various ways. Examples of waysinformation about SMIs is received include staff, practitioner, provider, member,governmental reports, and publications.SMIs include but are not limited to:Completed suicides.Severe suicide attempts/self inflicted injury.Apparent serious physical accidents/suspicious deaths.Adverse effects of medications requiring medical intervention.Member injury due to restraint/seclusion.Apparent homicide or serious physical assault by client.Life threatening injury or illness while on provider site requiring hospitalization.Sexual/physical abuse complaint by member against provider.Sexual abuse/physical assault complaint incurred by member at provider site.Failure to follow mandated Childline reporting requirements.Elopement.Any fire requiring emergency services of the fire department.Arrest of a member active in treatment.All incidents must be reported to Community Care within 24 hours of the incidentoccurring or within 24 hours of learning of the incident.ProcedureCommunity Care has developed a plan for significant incidents that ensures promptreview of the detail related to each incident and determining needed follow-up. Thisprocess will coordinate communication between the provider, Community Care, thecounty, and the oversight agency. As a result, duplication of reports will be minimal andfurther contact with the provider specific.Providers should report SMIs to Community Care within 24 hours of the incidentoccurrence or of the provider learning of the incident. The provider will informCommunity Care when they become aware of any loss of life during treatment or within30 days of treatment.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 198

The individual receiving information about a SMI initiates the Significant MemberIncident Form and enters the information into a database. At a minimum, the dataelements include:Date information about when the SMI is received.Date SMI occurred.Member name and identification number.Provider name and contact number.Nature of the SMI.All SMIs are forwarded to the quality clinician, SMI coordinator within one business dayof the date the information became known to Community Care. The quality clinician,SMI coordinator:Reviews the issue thoroughly and determines the urgency of the SMI.Determines the appropriate individual to investigate the SMI.Notifies the Chief Medical Officer or designee about the SMI [each occurrence ofunexpected and undesirable outcome that has an adverse impact on the outcome ofcare must be thoroughly reviewed by the Chief Medical Officer or designee]. Seniormanagement determines when legal counsel should be informed about a SMI.Documents all information and actions on the Significant Member Incidents Form.Contacts the provider or others as needed.Obtains additional information, as needed to conduct a thorough investigation of theSMI, including any aspects of clinical care and safety involved.Obtains the medical records from the provider, if necessary.Conducts an office site visit if needed for issues such as office safety.Tracks the SMI to resolution.A written report of the findings of the review including any recommendations iscompleted for each SMI. A copy of the completed SMI investigation results will beforwarded to the county/oversight agency when indicated.Identifying and monitoring SMIs is part of the quality improvement activities, whichCommunity Care performs as part of our comprehensive provider evaluation process(CPEP). Community Care will direct any media inquiries regarding SMIs to the SeniorDirector of Quality Management and inform the members of senior management atCommunity Care of the incident.Providers are expected to report all cases of child abuse to the appropriate reportingagency as defined by law. They are also expected to report this to Community Carewhen it involves one of our members. We will track this through our SMI reportingmechanisms. The provider may report this either verbally or in writing. The Childlinephone number for reporting suspected cases of child abuse is 1-800-932-0313.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 199

Orientation and ongoing provider education concerning this policy will occur through theprovider manual, provider education and training processes, and on a one-to-one basis,as necessary, with providers. SMIs that are considered serious will be contained in theprovider benchmarking review for recredentialing purposes. This process is a part of thecomprehensive provider evaluation process (CPEP) and will include monitoring providerstandards of practice as well as their timely response in addressing incidents identified.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 200

APPENDIX B.1. Consents for Release of Information Forms and for PhysicalHealth/Behavioral Health CollaborationCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 201

CONSENT FOR RELEASE OF INFORMATIONMENTAL HEALTHI hereby authorize __________________________________________________ to(name of facility, agency, school or person)release information from the records of:_______________________________________/_____________/_________________(name of Member) (DOB) (Med. Rec. #)For the specific purpose of:METHOD OF RELEASE (must check one): Verbal Only Copies Only Both The information to be released is: (Please check all that apply)Psychiatric EvaluationMedical HistorySocial HistoryDischarge SummaryCourse of TreatmentNeurologicalsLaboratory ReportsOther:Psychological/Achievement TestsDevelopmental HistoryAcademic/School RecordsSummary of HospitalizationTreatment RecommendationsMedicationOther Records (specify):Please forward information to theattention of:Facility/agency/person:Address:Phone:I have been told that, in order to protect the limited confidentiality of records, my agreement toobtain or release information is necessary and that this permission is limited for the purposes andto the person listed above, and will be effective for 90 days after the date of my signature, unlessspecified below. I also understand that this consent is revocable, by contacting the CommunityCare Privacy Officer in writing, except to the extent that action has been taken in reliance thereon.We will not condition treatment, payment, enrollment in Community Care Behavioral HealthOrganization, or eligibility for benefits on the person providing authorization for the requested useor disclosure.This consent shall be in effect from ____________________ until _____________________Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 202

(Date of signature)__________________________________(Witness)______________________________________Signature of Patient (14 years of age or older)______________________________________Signature of Parent/Legal Guardian/AuthorizedRepresentativeI do do not want a copy of this release____________________________________________________________________________________Oral Consent(Not Applicable to HIV-Related Information)For persons physically unable to provide a signatureI witnessed that the person understood the nature of this release and freely gave his/her oralconsent.Date of Signature:Signature of Witness:Date of Signature:Signature of Witness:Prohibition of redisclosure: The information has been disclosed to you from recordswhose confidentiality is protected by Federal Law. Federal regulations prohibit you frommaking any further disclosure of this information except with the specific written consentof the person to whom it pertains or as otherwise permitted by such regulations. Ageneral release of medical or other information is not sufficient for this purpose.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 203

Authorization for the Release of Drug and AlcoholInformation to the BHMCOI, ________________________________, authorize _________________________________(Provider)to release the following information to:Care Manager: ______________________________________________________________Community Care Behavioral Health OrganizationOne Chatham Center, Suite 700112 Washington PlacePittsburgh, PA 15219For the purpose of determining the advisability of certain treatment to coordinate myclinical care. Such authorization shall be limited to the following information:1. My presence in treatment2. Prognosis and diagnosis3. Nature of the treatment program4. Description of the treatment program5. Relapse statusThis release of information covers the treatment dates beginning ____________________and ending ________________________________.I may revoke this consent in writing to the Community Care Privacy Officer at any timeexcept as to any information released in reliance thereon to the date of such revocation.This consent will automatically expire 120 days from the date signed.I have been offered and have accepted/rejected a copy of this form (*please circle one)__________________________________________________Signature of Member__________________________________________________Signature of Witness_______________________Date_______________________DateI hereby revoke this consent effective ________________________. I understand that thisrevocation has no effect on information released prior to the date of this revocation.__________________________________________________Signature of Member_______________________DateProhibition of redisclosure: The information has been disclosed to you from recordswhose confidentiality is protected by Federal Law. Federal regulations prohibit you frommaking any further disclosure of this information except with the specific written consentof the person to whom it pertains or as otherwise permitted by such regulations. Ageneral release of medical or other information is not sufficient for this purpose.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 204

Authorization for the Release of Specific InformationI, ________________________________, authorize _________________________________(Provider)to release the following information to:Care Manager: ______________________________________________________________Community Care OrganizationOne Chatham Center, Suite 700112 Washington PlacePittsburgh, PA 15219For the purpose of determining the advisability of certain treatment to coordinate myclinical care. Such authorization shall be limited to the following information:1. My presence in treatment2. Prognosis and diagnosis3. Nature of the treatment program4. Description of the treatment program5. Relapse statusThis release of information covers the treatment dates beginning ____________________and ending ________________________________.I may revoke this consent in writing to the Community Care Privacy Officer at any timeexcept as to any information released in reliance thereon to the date of such revocation.This consent will automatically expire 120 days from the date signed.HIV related information contained in the parts of my clinical record may be released through this consentunless otherwise indicated: (Check one)_____ Consent to release of HIV information_____ Do not release HIV informationSignature to permit release of HIV/AIDS information contained in my medical records:__________________________________________________________________________________________________________________________________________________________Date_________________________DateI have been offered and have accepted/rejected a copy of this form (*please circle one)__________________________________________________Signature of Member__________________________________________________Signature of Parent/Guardian (when patient is under 14)_______________________Date_______________________DateCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 205

__________________________________________________Signature of Witness_______________________Date____________________________________________________________________________ORAL CONSENT (only for persons physically unable to provide a signature)I witnessed that __________________________ (Member’s name) understood the natureof this Consent to Release, understood that s/he may orally revoke this consent at anytime except as to the information released in reliance thereon to the date of such oralrevocation and that s/he freely gave his/her oral consent. (Two witnesses required)__________________________________________________Witness__________________________________________________Witness_______________________Date_______________________DateI hereby revoke this consent effective ________________________. I understand that thisrevocation has no effect on information released prior to the date of this revocation.__________________________________________________Signature of Member_______________________DateProhibition of redisclosure: The information has been disclosed to you from recordswhose confidentiality is protected by Federal Law. Federal regulations prohibit you frommaking any further disclosure of this information except with the specific written consentof the person to whom it pertains or as otherwise permitted by such regulations. Ageneral release of medical or other information is not sufficient for this purpose.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 206

Sample Letter for Permission to Share Information forCollaboration between Physical Health and Behavioral Health Organizationsor Practitioners(Practice Letterhead)Primary Care Physician/Behavioral Health Clinician Name:Address:Fax #Date_______________________________________________________________________________________________________________Dear Provider:Your patient, ___________________________________, is being treated forsymptoms of ___________________________________.I/We have recommended the following treatment: ______________________________________________________________________________________________________________________________________________________________________________ Individual Therapy____ Group Therapy____ Pharmacotherapy____ Family/Couples Therapy____ Psychiatric Evaluation for Medication____ No treatment recommended at this timeThe following medication(s) have been prescribed:Medication: ______________________________Dose/frequency: ______________________________ No medication at this timePlease feel free to contact me at (xxx-555-5555) if you feel there are coordination ofcare issues that we should discuss.Sincerely,(Provider name, title, signature)Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 207

APPENDIX C.1. Priority PopulationsMENTAL HEALTH - ADULTIn order to be in the Adult Priority Group, a person: must meet the federal definition ofserious mental illness 1 ; must be age 18+, (or age 22+ if in Special Education); musthave a diagnosis of schizophrenia, major affective disorder, psychotic disorder NOS orborderline personality disorder (DSM-IV or its successor documents as designated bythe American Psychiatric Association, diagnostic codes 295.xx, 296.xx, 298.9x or301.83); and must meet at least one of the following criteria:A. Treatment HistoryB. Functioning Level orC. Coexisting Condition or CircumstanceA. TREATMENT HISTORYCurrent residence in or discharge from a state mental hospital within the past twoyears; orTwo admissions to community or correctional inpatient psychiatric units or residentialservices totaling 20 or more days within the past two years; orFive or more face-to-face contacts with walk-in or mobile crisis or emergencyservices within the past two years; orOne or more years of continuous attendance in a community mental health or prisonpsychiatric service (at least one unit of service per quarter) within the past two years;orHistory of sporadic course of treatment as evidenced by at least three missedappointments within the past six months, inability or unwillingness to maintainmedication regimen or involuntary commitment to outpatient services; orOne or more years of treatment for mental illness provided by a primary carephysician or other non-mental health agency clinician, e.g., Area Agency on Aging,within the past two years.B. FUNCTIONING LEVELGlobal Assessment of Functioning Scale (DSM-IV-TR, pages 12 and 20) rating of 50 orbelow.______________________1 Adults with serious mental illness are persons age 18 and over, who currently or at any time during thepast year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meetdiagnostic criteria specified within DSM-IV that has resulted in functional impairment which substantiallyinterferes with or limits one or more major life activities. (See Reference for additional detail)Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 208

C. COEXISTING CONDITION OR CIRCUMSTANCE1. Coexisting Diagnosis:a. Psychoactive Substance Use Disorder; orb. Mental Retardation; orc. HIV/AIDS; ord. Sensory, Developmental and/or Physical Disability; or2. Homelessness 2 ; or3. Release from Criminal Detention 3In addition to the above, any adult who met the standards for involuntary treatment (asdefined in Chapter 5100 Regulations - Mental Health Procedures) within 12 monthspreceding the assessment is automatically assigned to the high priority group.MENTAL HEALTH - CHILD AND ADOLESCENTThe Child and Adolescent First Priority Group includes persons who meet all fourcriteria below:1. Age: birth to less than 18 (or age 18 to less than 22 and enrolled in specialeducation services).2. Currently or at any time in the past year have had a DSM-IV diagnosis (excludingthose whose sole diagnosis is mental retardation or psychoactive substance usedisorder or a "V" code) that resulted in functional impairment which substantiallyinterferes with or limits the child's role or functioning in family, school, orcommunity activities.3. Receive services from mental health and one or more of the following:a. Mental Retardationb. Children and Youthc. Special Educationd. Drug and Alcohole. Juvenile Justicef. Health (the child has a chronic health condition requiring treatment).4. Identified as needing mental health services by a local interagency team, e.g.,CASSP Committee, Cordero Workgroup.In addition to the above, any child or adolescent who met the standards for involuntarytreatment within the 12 months preceding the assessment (as defined in Chapter 5100– Mental Health Procedures) is automatically assigned to this priority group._______________________2 Homeless persons are those who are sleeping in shelters or in places not meant for human habitation,such as cars, parks, sidewalks or abandoned buildings.3 Applicable categories of release from criminal detention are jail diversion; expiration of sentence orparole; probation or Accelerated Rehabilitation Decision (ARD).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 209

Second priority is associated with children at-risk of developing a serious emotionaldisturbance by virtue of: A parent's serious mental illness. Physical or sexual abuse. Drug dependency. Homelessness. Referral to the Student Assistance Programs.DRUG AND ALCOHOLThe priority population for drug and alcohol treatment services includes: Pregnant Females and Women with Children. Intravenous Drug Users. Adolescents. Persons with Severe Medical Conditions, such as Tuberculosis or HIV/AIDS. Mentally Ill Substance Abusers.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 210

APPENDIX D.1. Behavioral Health Managed Care Organizations (BH-MCOs)Performance/Outcome Management System (POMs)OVERVIEWThe POMS consists of a database that is updated on a periodic basis through batchdata file extracts that are obtained from a variety of data sources (see attached table ofoutcome measures and data sources). The database, which is maintained andmanaged by the Department of Public Welfare (DPW), contains an extensive array ofraw data concerning enrollees in the BH-MCOs. The primary purpose of the database isto serve as the basis for producing a set of performance measures/indicators. DPW willutilize the performance measures/indicators as its primary tool for continuouslyevaluating the effectiveness of the BH-MCO contractors in achieving a variety ofsystems level outcomes.The POMS serves the following primary functions:1. Provides accountability for public funds expended through DPW’s capitationpayments to the BH-MCO contractors.2. Provides a fair and objective evaluation of the BH-MCOs that DPW can use forimplementing outcome oriented incentives and sanctions.3. Supports DPW and the BH-MCO contractors to implement a collaborativecontinuous quality improvement process.DATA COLLECTION PROCESSESRaw data concerning BH-MCO enrollees, obtained from a variety of sources, will betransmitted via batch file extracts to the POMS central database (see attached flowchart). The data will be linked and integrated for each BH-MCO enrollee based onunique identifiers. The integrated database will provide the basis for DPW to derivequantitative performance indicators/measures that reflect systems level outcomesachieved by each BH-MCO primary contractor. The primary data sources and datacollection processes are as follows:1. BH-MCO Encounter Data - BH-MCOs, through a process similar to what theDepartment required for the HealthChoices PH-MCOs, will submit data files on aregular schedule to DPW. The data will be edited and then loaded into DPW’sEnterprise Data Warehouse. The Office of Mental Health and Substance AbuseServices (OMHSAS) will, on a regular schedule, receive a file of all DPW acceptedencounter records and will perform additional edits before loading to the POMScentral database.2. Enrollee Eligibility and Demographic Data - DPW will on a regular schedulemove enrollee eligibility and demographic data from its Client Information System(CIS) into the Enterprise Data Warehouse. OMHSAS will subsequently pull a subsetof eligibility and demographic data elements via data file extracts into the POMScentral database.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 211

3. Secondary Data - OMHSAS will develop data exchange agreements with otherstate agencies, as feasible; to obtain regularly scheduled data file extracts that willbe loaded into the POMS central database. Data exchanges with state agenciessuch as the Department of Corrections, State Police, and the Department ofEducation are under development.4. Consumer/Family Satisfaction Reports - There will be standardized measuresadministered by the BH-MCO. The BH-MCO will submit reports of findings to theDPW. A survey will be conducted annually.5. BH-MCO Consumer Registry File - BH-MCOs will maintain a computerizedregistry of their enrollees who have accessed behavioral health services. Theregistry is comprised of a minimum data set including clinical descriptions such aspriority population and critical dates during the episode of care such as date of firstservice request, registration date, and termination date. These data will be submittedby the BH-MCOs to the POMS central database.6. BH-MCO Quarterly Status File - BH-MCOs will maintain a computerized fileconcerning the status of priority populations. The file will be updated on a calendarquarter basis for each enrollee in the priority population. The quarterly status file iscomprised of a minimum data set including outcome measures such asvocational/educational status and independence of living arrangement. These datawill be submitted by the BH-MCOs to the POMS central database on a regularschedule.Please note: Providers contracted with the BH-MCO are required to submit POMS data quarterly for allnew members receiving behavioral health services during the quarter. Providers are expected to submitupdates to POMS data every six months for members in continuous care. Providers may submit POMSdata by completing individualized member specific POMS data collection paper surveys or by electronicfile submission using specifications developed by Community Care. For those submitting paper POMSdata, providers will be notified of members for whom POMS data is required each quarter through theconfidential mailing of individualized, member specific POMS Data Collection Survey forms. Instructionsfor completing the POMS Data Collection Survey are printed on the back of each individual form.7. Performance Indicator Reports - On a regular schedule, DPW will produce fromthe POMS central database a set of performance indicators that measure theperformance of each BH-MCO consistent with the outcome dimensions outlined inthe attached table of outcome measures. The performance indicator reports will beissued by DPW on a regular schedule to all relevant DPW monitoring staff, the BH-MCOs and other stakeholder groups.CONTINUOUS QUALITY IMPROVEMENT (CQI) PROCESSDPW encourages the BH-MCOs to implement a continuous quality improvement (CQI)process based upon Deming’s 14-point program adapted to the health care industry,and Joint Commission on Accreditation of Health Care Organization (JCAHO)guidelines. The overall process should include:Delineating the scope of the services to be monitored and improved.Identifying the important aspects of the services whose quality should be examinedand improved.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 212

Identifying indicators (including but not limited to the performance indicatorsestablished by DPW) that will be used to monitor the quality, accessibility, andappropriateness of the important aspects of services.Establishing thresholds (including but not limited to the thresholds established byDPW) for the review of indicators that become “flags” signaling the need for furtheranalysis of the causes for the data reported to DPW.Collecting data pertaining to each indicator and comparing the aggregate level ofperformance with the threshold for analysis. If the threshold is not reached, furtheranalysis may not be necessary.Initiating analyses of other important aspects of services when thresholds have beenreached.Taking actions to improve the aspects of services.Reporting the findings to the organizations involved, including a report of findings toDPW on a regular schedule. Monitoring and analysis are continued in order toidentify any future deficiencies in services and to improve quality. DPW monitoringstaff will review the CQI reports of findings submitted by the BH-MCOs. DPWmonitoring staff will provide feedback to BH-MCOs indicating:• Concurrence with the BH-MCOs explanation/cause of the performance Indicatorfindings and actions proposed by the BH-MCOs to improve performance (and/orcorrect deficiencies); or• Offer alternative explanations/causes for the performance indicator findingsand/or recommended alternative actions to improve performance (and/or correctdeficienciesCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 213

BEHAVIORAL HEALTH MANAGED CARE ORGANIZATIONSPERFORMANCE/OUTCOME MANAGEMENT SYSTEMOUTCOME DIMENSIONS1. Increase Community Tenure and LessRestrictive Services*• Increase the appropriate use of behavioralhealth inpatient days• Decrease criminal incarcerations• Increase the appropriate use of MHresidential care• Decrease out-of-home placements• Decrease homelessness• Decrease placement in C&Y custody• Increase residential stabilityDATA SOURCE(S)1. Quarterly Status File (QSF) 12. Criminal incarceration data sets from statecorrectional3. BH encounter data and SMH data set (PCIS)*To be reported/compiled only for priority groupconsumers by age group (under age 21, 21-64, andage 65+)2. Increase Vocational and Educational Status*• Increase school attendance (full time regularclassroom)• Increase school retention• Increase school performance• Improve school behavior• Increase vocational status for adults1. Quarterly Status File (QSF) 12. Employment tax records*To be reported/compiled only for priority groupconsumers by age group3. Reduce Criminal/Delinquent Activity*• Reduce number of arrests• Reduce positive drug screens• Improve probation/parole status• Reduce status offenses (focus on truancy)*To be reported/compiled only for priority groupconsumers by age group4. Improve Health Care*• Meet or exceed DPW’s EPSDT screening• Increase % of consumers with annualphysical exams• Reduce hospital medical ER use1. Quarterly Status File (QSF) 12. Arrest records (state police)3. Probation and parole records4. Automated Health Systems5. A.O.P.C. records1. Encounter data from physical health HMOs2. Behavioral Health Encounter File (BHEF) 3*To be reported/compiled only for priority groupconsumers by age group5. Increase “Penetration Rates” (i.e., percent ofenrollees who received behavioral healthtreatment through the behavioral health1. Consumer Registry File (CRF) 22. Behavioral Health Encounter File (BHEF) 3Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 214

contractor)• Increase appropriate utilization by prioritygroup and type of service• Increase appropriate utilization by age andtype of service3. Automated Health Systems6. Increase Consumer/Family Satisfaction**To be reported/compiled only for priority groupconsumers by age group1. Consumer Registry File (CRF) 22. Consumer/Family Satisfaction MeasurementInstruments7. Implement Continuous Quality Improvement(CQI) Actions1. CQI Periodic Reports – Behavioral healthcontractor must submit to DPW periodicnarrative reports detailing its CQI activities,delineating deficiencies and areas forimprovement, actions taken to improveperformance (or remedy deficiencies) and theeffectiveness/outcome of actions taken. CQIreports must address performance indicatorreports issued by OMH.8. Increase Range of Services and Improve 1. Behavioral Health Encounter File (BHEF) 3Utilization Patterns• Improve/increase the array of treatment, 2. Encounter data from physical MCOssupport and rehabilitative service options• Decrease % of priority group consumersusing only inpatient and/or ER services• Reduce inpatient rehospitalization rate• Reduce rate of perinatal addictive disorders• Reduce “drop-out” rate•1 Reporting requirements and Data elements for QSF are in the Proposers’ Library2 Reporting requirements and Data elements for CRF are in the Proposers’ Library3 Reporting requirements and Data elements for BHEF are in the Proposers’ LibraryCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 215

APPENDIX E.1. Companion Guide for Northeast CountiesCommunity Care Behavioral Health OrganizationHealthChoices Provider Manual Companion Guide forLackawanna, Luzerne, Susquehanna, and Wyoming CountiesTable of Contents Page 4 The Northeast Behavioral Healthcare Consortium(NBHCC) will publish member handbooks.Guidelines for Obtaining Approvalfor In-Plan and SupplementalServices – Mental HealthPage 8 Mobile, Telephone, and Walk-In Crisis servicesare authorized via the submission of a FacsimileTransmittal request form within 24 hours of eachmember occurrence.Initial non-MD Evaluation is not a covered service.Designated Providers only.NBHCC counties do not differentiate the benefitfor levels of partial hospitalization mental health;all partial services follow a standard partial benefitGuidelines for Obtaining Approvalfor In-Plan and SupplementalServices – Chemical DependencySection I.C. Overview of QualityManagementAcute Partial HospitalizationStandardsCommunity Treatment TeamPerformance StandardsDiversion and Acute Stabilization(DAS) Performance StandardsDrug and Alcohol PartialHospitalization PerformanceStandardsSchool Based Partial HospitalizationPrograms Performance StandardsPage 12Page 17and reimbursement.Initial non-MD Evaluation is not a covered service.Designated Providers only.NBHCC clinical parameters for Partial D&A are asfollows:Must meet PCPC; Partial D&A services must bebetween three and four hours per day; maximum12 hours per week. In general, member is notexpected to be receiving other treatment (asopposed to support or rehabilitation) services inany other levels of care during partial hospitalstay. Length of stay should not exceed four to sixweeks unless approved by Community Care.Quality Management Plans and Responsibilitieswill be developed in concert with NBHCC.* NBHCC counties do not differentiate the benefitfor levels of partial hospitalization; all partialservices follow a standard partial benefit andreimbursement.* Performance standards can be found on the Community Care website at:www.ccbh.com/providers/phealthchoices/performancestandardsCommunity Treatment Teams (CTT) are not acovered service.Diversion and Acute Stabilization (DAS) is not acovered service.D&A Partial Performance Standards do notcurrently apply. NBHCC counties do notdifferentiate the benefit for levels of hospitalizationdrug & alcohol outside of clinical parametersoutlined on Page 10.School Based Partial Performance Standardswere developed for Approved Private Schools orPrivate Academic School Settings. NBHCC hasestablished a differential code for partial hospitalservices within a school setting but will notdifferentiate the benefit or reimbursement.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 216

APPENDIX F.1. Companion Guide for North Central CountiesGuidelines for Obtaining Approvalfor In-Plan and SupplementalServices – Mental HealthCommunity Treatment TeamPerformance StandardsDiversion and Acute Stabilization(DAS) Performance StandardsCommunity Care Behavioral Health OrganizationHealthChoices Provider Manual Companion Guide forHealthChoices North CentralPage 8 Mobile, Telephone, and Walk-In Crisis servicesare authorized via the submission of a FacsimileTransmittal request form within 24 hours of eachmember occurrence.* Community Treatment Teams (CTT) is not acovered service.Diversion and Acute Stabilization (DAS) is not acovered service.* Performance standards can be found on the Community Care website at:www.ccbh.com/providers/phealthchoices/performancestandardsCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 217