Billing Manual for Community Care Network Providers

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• 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
Coordination of Benefits (COB) claims received outside of the initial timely fileguidelines must be received within 30 days from the date printed on the primaryexplanation of benefits (EOB).Secondary Electronic Claim Submission:Only secondary outpatient claims can be submitted electronically via an 837Professional file. Electronic files can be received either via a claims clearinghouse orsubmitted directly via Community Care’s Provider Online Website in an 837 professionalfile format only. If submitting secondary EDI files directly to Community Care providersare required to submit one small test file of 2-3 claims. Below are our secondary EDIrequirements:OIC PaidDeductibleCoinsCopayOIC adjustment reason codes - For reference:http://www.wpc-edi.com/content/view/698/1Professional ClaimsCommunity Care Behavioral Health requires the submission of all COB relevant data.The NM1 segment containing the name and ID of primary insurance companyThe SVD segment and all supporting CAS segments at the service level.The primary insurance allowed amount at the service level is very helpful, but notrequired.Understanding Claim CorrectionsIf you receive a payment that you believe is an underpayment or an overpayment youwill need to initiate a claim correction. Clarification of denials can be obtained by callingthe Provider Line, 1-888-251-2224, and following the prompts for ProviderReimbursement. Community Care strongly recommends that all claim corrections aresubmitted electronically (837I, 837P, or Prelog). Community care will accept a UB-04 ora CMS-1500 form with “Corrected Claim” and the form/claim number written on the top.You must indicate which components of the original claim form you are correcting bydrawing a line through or circling the error. Make sure the correction is clearly identified.Community Care cannot process a claim correction based on any Provider’sAccounts Receivable listing, Community Care remittance advice, or a ProviderOnline screen print.Claim Correction Requirements:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 115
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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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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 74 and 75: When such disclosure to health care
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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
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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 112 and 113: 67a-q Diag. Code Required68 Unlabel
Page 116 and 117: Many of the services covered by Com
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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
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Page 152 and 153: esults, billing records, and treatm
Page 154 and 155: equestor destroy the information, o
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Page 160 and 161: y the written authorization of the
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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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