Billing Manual for Community Care Network Providers

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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
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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
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members, practitioners are asked to
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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
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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
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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 110 and 111: 17 Discharge Status Required forINP
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
Page 160 and 161: 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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