Billing Manual for Community Care Network Providers

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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
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APPENDIX A.2. Confidentiality 130AP
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Clinical Fax by County:Adams 1-866-
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Outpatient Therapy 1MD OutpatientMe
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Functional Familytherapy (FFT)Multi
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Non-Acute PartialHospitalizationNot
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I.A. Code of EthicsCommunity Care
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esources and evaluated on their pro
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Confidentiality policies including
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Within 30 minutes for urban areas.W
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I.E. Care Management Team“Advocat
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In order to serve special populatio
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Psychiatric Rehabilitation Clubhous
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always be considered in light of th
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Tell their provider everything they
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and calls received on the programs
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II.D.1e EvaluationIndividuals parti
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II.D.2b GoalsThe goals of Community
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II.D.3 Providers’ Role in the Pre
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Community Care has a total of 30 ca
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Department of Health and provide in
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An explanation of the grievance pro
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Upon request, the member will be as
Page 54 and 55: Notices must be in alternate format
Page 56 and 57: Community Care is a party to the he
Page 58 and 59: The following sections provide info
Page 60 and 61: members, practitioners are asked to
Page 62 and 63: Accreditation of Healthcare Organiz
Page 64 and 65: III.B.4 Facility ReassessmentFacili
Page 66 and 67: present relevant information, and t
Page 68 and 69: contracting, performance evaluation
Page 70 and 71: the implementation and application
Page 72 and 73: III.C.4 Ability to Give Informed Au
Page 74 and 75: When such disclosure to health care
Page 76 and 77: Practitioners are informed of the r
Page 78 and 79: Medication(s) that have been prescr
Page 80 and 81: III.E. Clinical Practice Guidelines
Page 82 and 83: Community Care has developed a plan
Page 84 and 85: eing served and uses strategies to
Page 86 and 87: dialogue and intervention may occur
Page 88 and 89: For any questions about providing s
Page 90 and 91: If you, as a Community Care provide
Page 92 and 93: When the precertification is for se
Page 94 and 95: ORA member expresses a readiness fo
Page 96 and 97: IV.E.3 Transition of Care to anothe
Page 98 and 99: Billing ManualCommunity Care Behavi
Page 100 and 101: Even though an authorization may be
Page 102 and 103: Timely File requests are to be mail
Page 106 and 107: Required Claim FieldsIn the followi
Page 108 and 109: 24C EMG Not required24D Procedure C
Page 110 and 111: 17 Discharge Status Required forINP
Page 112 and 113: 67a-q Diag. Code Required68 Unlabel
Page 114 and 115: • Explanation of Benefits (EOB) i
Page 116 and 117: Many of the services covered by Com
Page 118 and 119: Community Care Behavioral Health Or
Page 120 and 121: Community Care Procedure Code: The
Page 122 and 123: C/FST: Consumer/Family Satisfaction
Page 124 and 125: Medicaid/Medical Assistance identif
Page 126 and 127: APPENDICESAPPENDIX A.1. Fraud, Wast
Page 128 and 129: . The provider will also receive a
Page 130 and 131: APPENDIX A.2. ConfidentialityPOLICY
Page 132 and 133: A Facility or group practice name,
Page 134 and 135: Confidential data and information s
Page 136 and 137: The medical director or his/her des
Page 138 and 139: The privacy officer will review the
Page 140 and 141: collection and use of member identi
Page 142 and 143: Protection of information disclosed
Page 144 and 145: If a member is granted access to re
Page 146 and 147: Under some circumstances, it may be
Page 148 and 149: 164.504(e)(ii)(A)).They will take a
Page 150 and 151: must verify that the member has sig
Page 152 and 153: esults, billing records, and treatm
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equestor destroy the information, o
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The member has the right to request
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Policy on Release of Information Re
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y the written authorization of the
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If minor consents to treatment or c
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Current patients or clients or the
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If the client has given written aut
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Confidentiality policies pursuant t
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“Statement of Confidentiality”
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Findings will be reported to senior
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information and by signing this sta
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Community Care has identified circu
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NameAddress (es)Zip CodeDiagnosis (
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Community Care has the right to den
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Member identifiable information may
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Community Care extends all reasonab
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For research purposes.On behavioral
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See the policy on Transition of Pri
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Community Care does not collect inf
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The request must be in writing. Cre
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All statements to the media includi
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• The name, or title, and the tel
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APPENDIX A.4. Significant Member In
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Orientation and ongoing provider ed
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CONSENT FOR RELEASE OF INFORMATIONM
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Authorization for the Release of Dr
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___________________________________
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APPENDIX C.1. Priority PopulationsM
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Second priority is associated with
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3. Secondary Data - OMHSAS will dev
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BEHAVIORAL HEALTH MANAGED CARE ORGA
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APPENDIX E.1. Companion Guide for N
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