Billing Manual for Community Care Network Providers

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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
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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
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Notices must be in alternate format
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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
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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
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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 104 and 105: Provide an alternative to the use o
Page 106 and 107: Required Claim FieldsIn the followi
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
Page 154 and 155: equestor destroy the information, o
Page 156 and 157: 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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