Billing Manual for Community Care Network Providers

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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
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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
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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 104 and 105: Provide an alternative to the use o
Page 106 and 107: Required Claim FieldsIn the followi
Page 108 and 109: 24C EMG Not required24D Procedure C
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
Page 158 and 159: 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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Billing Manual for Community Care Network Providers

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