Billing Manual for Community Care Network Providers

. The provider will also receive a list of members’ charts to be reviewed at this time.c. No documentation will be accepted after the audit day has passed. In the case ofdesk audits, no documentation will be accepted after the initial charts are receivedby the auditing team. After completion of the audit, an exit interview is conductedwith appropriate provider program directors and administrators.d. Providers are informed during the exit interview that any reimbursements owed toCommunity Care may be directly deducted from future claim payments. Directrepayment may also be requested. Payments are due to Community Care within 30days from the date of the audit results letter. This information is also explained in theaudit results follow-up letter that is sent to the provider within two weeks after thecompletion of the audit.e. If the routine audit reveals a pattern of suspected fraud, waste, or abuse, CommunityCare must report the activity to the BPI within 30 business days, in accordance withregulatory requirements and the Community Care Fraud and Abuse Policy andProcedure. The appropriate county/counties and/or oversight entity will be notifiedwithin the same 30 day time period.f. If the audit reveals an area of non-compliance involving any issues not reflective ofsuspected fraud, waste, or abuse, a letter may be sent to the provider withinstructions to follow regarding submission of a corrective action plan and a directiveto contact Community Care in writing within 30 business days with any questions,concerns, or appeals.g. If the provider does not contact Community Care within 30 business days with anyquestions or concerns, it is assumed that the provider agrees with the findings of theaudit and will comply with corrective actions plans and reimbursement plans, whereapplicable.h. After the 30 day waiting period has passed, a copy of the letter is forwarded to theCommunity Care credentialing and network management departments. Letters willbe forwarded to the county/counties and/or oversight entities whenever the lettersare sent out to the providers.i. Based on results of the original audit, Community Care may conduct a follow-upaudit within 3-6 months of the previous audit final disposition.j. On a periodic basis the FWA Department will share audit exception trends with theprovider community. The audit findings will be communicated to providers throughvarious channels which include but are not limited to provider newsletters and FWADepartment Provider Alerts.The auditing process for referral audits is outlined below.a. The FWA Department accepts referrals from external and internal stakeholders.b. Both external and internal referrals can be made anonymously. Internal referralscan also be submitted through the employee’s manager or director.c. The FWA Department notifies the appropriate regional director/directors and the Sr.Director of Network Management of external referrals that have been submitted, forexample, by members through our Fraud and Abuse Hotline, or by the membernotifying the care management or network departments, by the Bureau of ProgramIntegrity, or by a county administrator of one of the HealthChoices contracts.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 128