Billing Manual for Community Care Network Providers

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Community Care Procedure Code: The code assigned to a service and defined on theCommunity Care Service Code Fee Schedule.Community Care Modifier: A two character code attached to a procedure code toidentify a different service, to allow a unique rate, or to facilitate reporting.OPR: Outpatient Registration – Community Care’s method for notification by providersof members receiving ‘outpatient’ services.Provider Online: Community Care’s web based application for submitting claimsdirectly and for checking the status of claims.Vendor: This is the name and address which appears on the Community CareRemittance Advice. The Vendor is associated with a Federal Tax ID defined by theprovider. The Vendor information on the claim form must match the information on theprovider’s contract or the claims will deny.TPL: Third Party LiabilityUnit of Service: The ‘billing unit’ defined on the Community Care Fee Schedule.NOTE: Your ‘charge collection units’ may need to be converted to ‘billing units’.Usual Charge: The amount charged by your agency, to all payers, for the service beingrendered.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 120
Glossary of Terms and AbbreviationsThe following terms and abbreviations are defined as they are used in the CommunityCare Provider Manual for HealthChoices providers.Abuse: Provider practices that are inconsistent with sound fiscal, business, or medicalpractices and result in unnecessary cost to the Medicaid program or in reimbursementfor services that are not medically necessary or that fail to meet professionallyrecognized standards for health care. Also, recipient, i.e., Community Care member,practices that result in unnecessary cost to the Medicaid program.ALOS: Average Length of StayASAM: American Society for Addiction MedicineAuthorization: An agreement that the services planned for a specific member meet“Medical Necessity Criteria”/level of care criteria. A provider must receive authorizationto provide the services for a claim to be honored, but receiving authorization is not apromise that the claim will be paid (other criteria must be met).BDAP: Bureau of Drug and Alcohol ProgramsBHMCO: Behavioral Health Managed Care Organization, e.g., Community CareBehavioral Health Organization.BHRSCA: Behavioral Health Rehabilitation Services for Children and Adolescents(formerly referred to as EPSDT or “wraparound”)BPI: Bureau of Program Integrity (Commonwealth of Pennsylvania)CARF: Committee on Accreditation of Rehabilitation FacilitiesCASSP: Child and Adolescent Service System ProgramsCBCL: Child Behavior Check ListCMS: Center for Medicare and Medicaid Services (previously HCFA/Health CareFinancing Administration)COA: Council on AccreditationComplaint: An oral or written expression of dissatisfaction from a member or providerthat initiates a formal investigation process.CSP: Community Support ProgramCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 121
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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
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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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Page 74 and 75: When such disclosure to health care
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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 106 and 107: Required Claim FieldsIn the followi
Page 108 and 109: 24C EMG Not required24D Procedure C
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Page 114 and 115: • Explanation of Benefits (EOB) i
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Page 122 and 123: C/FST: Consumer/Family Satisfaction
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Page 126 and 127: APPENDICESAPPENDIX A.1. Fraud, Wast
Page 128 and 129: . The provider will also receive a
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Page 132 and 133: A Facility or group practice name,
Page 134 and 135: Confidential data and information s
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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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