Billing Manual for Community Care Network Providers

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C/FST: Consumer/Family Satisfaction TeamDOH: Department of Health; the state agency responsible for licensing and inspectinghealthcare facilities and services and setting quality standards for providing care toHealthChoices (Medicaid, Medical Assistance) members.DOS: Date(s) of Service (most often used on claim forms and similar documents)DPW: Department of Public Welfare; the state agency that administers HealthChoicesand other Medicaid/Medical Assistance programs.EDI: Electronic Data Interchange; the computer software system used to encode andtransmit claims data electronically.Emergency: The sudden onset of a behavioral health condition manifesting itself byacute symptoms of sufficient severity, such that a prudent layperson who possesses anaverage knowledge of health and medicine could reasonably expect that the absence ofimmediate medical or clinical attention could result in seriously jeopardizing orendangering the mental health or physical well-being of the enrollee or seriouslyjeopardizing or endangering the physical well-being of a third party.EOB: Explanation of Benefits; statement to a provider showing the status of thatprovider’s outstanding claims with the insurer issuing the EOB (A.K.A. EOP –Explanation of Payment).EVS: Eligibility Verification SystemExpedited Member Grievance: A medical necessity determination grievance regardingan inpatient, acute partial, acute residential, 23-hour bed admission, or other urgent oremergent service, as determined by the member or provider.Fraud: An unintentional or unintended deception or misrepresentation made by aperson with the knowledge that the deception could result in some unauthorized benefitto himself or some other person.GAF: Global Assessment of Functioning (GAF score); a measure of mental healthdisability.Grievance: Formal mechanism for a member to disagree with Community Care’s denialbased on medical necessity of authorization for the level of care that the member andprovider deem is indicated. Filing a standard or expedited grievance starts a formalreview process. Community Care remains obligated to continue care for the memberuntil the grievance is resolved—up to a ruling from the state Department of Health.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 122
ICM: Intensive Case Management; a Community Care HealthChoices (Medicaid,Medical Assistance) covered service that includes coordination of multiple levels andtypes of services for a member with complex or rapidly changing care needs.LOC: Level of Care; inpatient versus partial hospitalization versus outpatient.LOF: Level of Functioning; a general term that includes specific measures such as GAF(Global Assessment of Functioning) scores.LOS: Length of Stay; continuous service days for an admission to a facility or program.MA: Medical Assistance (Medicaid)MATP: Medical Assistance Transportation Program; provides transportation (forexample, to mental health appointments) for HealthChoices (Medicaid, MedicalAssistance) members.MCO: Managed Care Organization (see BHMCO and PHMCO)MIS: Management Information SystemsMOE: Multicultural Outreach EducationNAMI: National Alliance on Mental IllnessNCQA: National Committee for Quality AssuranceNEIC: National Electronic Insurance Corporation; licensor of Envoy software used tobatch process Community Care Behavioral Health Organization claims submittedelectronically.OIC: Other Insurance CarrierOMHSAS: Office of Mental Health and Substance Abuse Services; a component of theDepartment of Public Welfare that administers policies regarding mental health andsubstance abuse issues.PCP: Primary Care PhysicianPCPC: Pennsylvania Client Placement Criteria (for chemical dependency)PHMCO: Physical Health Managed Care OrganizationPOSNET: Point of Service Network; a data transmission system with an electronic cardreader that a Community Care provider can use with HealthChoices members’Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 123
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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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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
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Page 78 and 79: Medication(s) that have been prescr
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 112 and 113: 67a-q Diag. Code Required68 Unlabel
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 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
Page 162 and 163: If minor consents to treatment or c
Page 164 and 165: Current patients or clients or the
Page 166 and 167: If the client has given written aut
Page 168 and 169: Confidentiality policies pursuant t
Page 170 and 171: “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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Billing Manual for Community Care Network Providers

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