Billing Manual for Community Care Network Providers

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Guidelines for Obtaining Approval for In-Plan and Supplemental ServicesChemical DependencyServiceEmergencyEvaluationPsychiatricOutpatientEvaluation orInitial Non-MDEvaluationOutpatientTherapy 1MethadoneMaintenance(Outpatient) 1IntensiveOutpatientTherapyAuthorizationTypeNoneAnnualRegistrationOnlyAnnualRegistrationOnlyNotification viaFacsimileTransmittalRequest FormLimits/Exclusions/DefinitionsFor a hospital, not reimbursed separately ifpatient is admitted within 24 hours to theevaluating facility.Initial: Registration must be submitted followingthe initial outpatient visit; not to exceed timelyfiling limits for claims submission for themember’s product coverage.Concurrent: Registration must be submittedprior to the expiration of the initial annualregistration period; not to exceed the timely filinglimits for claims submission for the member’sproduct coverage.REFER TO THE BILLING SECTION FORTIMELY FILING LIMITS FOR EACHHEALTHCHOICES PRODUCTUnit definition:Bundled = 1 week (methadone and treatment)Unbundled = 1 day (methadone only)Initial: Registration must be submitted followingthe initial outpatient visit; not to exceed the timelyfiling limits for claims submission for themember’s product coverage.Concurrent: Registration must be submittedprior to the expiration of the initial annualregistration period; not to exceed the timely filinglimits for claims submission for the member’sproduct coverage.REFER TO THE BILLING SECTION FORTIMELY FILING LIMITS FOR EACHHEALTHCHOICES PRODUCTMust meet PCPC or ASAM for adolescents;service is minimum of 5.0 and maximum of 9.75hours per week.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 12
Non-Acute PartialHospitalizationNotification viaFacsimileTransmittalRequest FormPrecertificationMust meet PCPC or ASAM for adolescents; atleast 3 visits per week with a minimum of 10hours per week.Acute PartialHospitalizationMust meet PCPC or ASAM for adolescents; atleast 3 visits per week with a minimum of 10hours per week.Halfway House Precertification Must meet PCPC or ASAM for adolescents forMedicallyManagedRehabilitationNon-HospitalResidentialRehabilitation (3B;short-term or 3C;long term)MedicallyManagedDetoxificationNon-HospitalDetoxificationDrug & AlcoholCaseManagement(ICM/RC)Drug & AlcoholLevel of CareAssessmentPrecertificationPrecertificationlevel 2B.Must meet PCPC or ASAM for adolescents forLevel 4B.Requires diagnoses on all 5 Axes; no V-codes.Must meet PCPC or ASAM for adolescents forlevel requested.Precertification Must meet PCPC for Level 4A.Requires diagnoses on all 5 Axes; no V-codes.Precertification Must meet PCPC for Level 3A.Notification;FacsimileTransmittalRequest FormNotification;FacsimileTransmittalRequest FormUnit definition: 1 unit = 15 minutes.Intake only – Maximum 8 units of service.Ongoing - Maximum of 300 units for a six monthtime frame.Unit definition: 1 unit = 15 minutes.Maximum of 8 units of service.1Outpatient registration (OPR): Annual registration of Member requiredCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 13
Page 5 and 6: APPENDIX A.2. Confidentiality 130AP
Page 7 and 8: Clinical Fax by County:Adams 1-866-
Page 9 and 10: Outpatient Therapy 1MD OutpatientMe
Page 11: Functional Familytherapy (FFT)Multi
Page 15 and 16: I.A. Code of EthicsCommunity Care
Page 17 and 18: esources and evaluated on their pro
Page 19 and 20: Confidentiality policies including
Page 21 and 22: Within 30 minutes for urban areas.W
Page 23 and 24: I.E. Care Management Team“Advocat
Page 25 and 26: In order to serve special populatio
Page 27 and 28: Psychiatric Rehabilitation Clubhous
Page 29 and 30: always be considered in light of th
Page 31 and 32: Tell their provider everything they
Page 33 and 34: and calls received on the programs
Page 35 and 36: II.D.1e EvaluationIndividuals parti
Page 37 and 38: II.D.2b GoalsThe goals of Community
Page 39 and 40: II.D.3 Providers’ Role in the Pre
Page 41 and 42: Community Care has a total of 30 ca
Page 43 and 44: Department of Health and provide in
Page 45 and 46: An explanation of the grievance pro
Page 47 and 48: Upon request, the member will be as
Page 54 and 55: Notices must be in alternate format
Page 56 and 57: 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
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Accreditation of Healthcare Organiz
Page 64 and 65:
III.B.4 Facility ReassessmentFacili
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present relevant information, and t
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contracting, performance evaluation
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the implementation and application
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III.C.4 Ability to Give Informed Au
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When such disclosure to health care
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Practitioners are informed of the r
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Medication(s) that have been prescr
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III.E. Clinical Practice Guidelines
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Community Care has developed a plan
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eing served and uses strategies to
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dialogue and intervention may occur
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For any questions about providing s
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If you, as a Community Care provide
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When the precertification is for se
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ORA member expresses a readiness fo
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IV.E.3 Transition of Care to anothe
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Billing ManualCommunity Care Behavi
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Even though an authorization may be
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Timely File requests are to be mail
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Provide an alternative to the use o
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Required Claim FieldsIn the followi
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24C EMG Not required24D Procedure C
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17 Discharge Status Required forINP
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67a-q Diag. Code Required68 Unlabel
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• Explanation of Benefits (EOB) i
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Many of the services covered by Com
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Community Care Behavioral Health Or
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Community Care Procedure Code: The
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C/FST: Consumer/Family Satisfaction
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Medicaid/Medical Assistance identif
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APPENDICESAPPENDIX A.1. Fraud, Wast
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. The provider will also receive a
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APPENDIX A.2. ConfidentialityPOLICY
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A Facility or group practice name,
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Confidential data and information s
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The medical director or his/her des
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The privacy officer will review the
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collection and use of member identi
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Protection of information disclosed
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If a member is granted access to re
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Under some circumstances, it may be
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164.504(e)(ii)(A)).They will take a
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must verify that the member has sig
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esults, billing records, and treatm
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equestor destroy the information, o
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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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