Billing Manual for Community Care Network Providers

• 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