Billing Manual for Community Care Network Providers

d. Each referral is unique and therefore the details for handling the referrals vary. Forexample, if a referral is submitted by a member alleging that prescribed servicesare not being provided but they believe that their provider is submitting claims forthose services, Community Care will request that the provider forward to the FWAdepartment the member’s record in its entirety. An examination of the time periodthat encompasses the allegation time period will be reviewed. The amount of timereviewed will vary from referral to referral. Community Care will then comparedocumentation to submitted claims in order to determine if the allegations havebeen substantiated.e. The Bureau of Program Integrity may also submit referrals directly to the FWADepartment. The appropriate regional director/directors involved as well as the Sr.Director of Network Management will be notified as necessary.Provider Fraud and Abuse Audit Appeal ProcedureCommunity Care provides a transparent review process that enables providers toappeal Fraud, Waste, and Abuse audit results. Oral and written instructions regardingthe appeal process are reviewed with providers at the conclusion of each audit.The audit appeal procedure is outlined below.a. The provider must submit a written notification via certified mail to the Fraud andAbuse auditor, postmarked within 10 business days from the date of their auditresults letter, of their intent to appeal any audit findings.b. If the provider does not submit their appeal to the FWA Department within 30business days, any subsequent request for an appeal will be denied.c. The provider must then submit, via certified mail, their detailed appeal in its entiretyto the FWA auditor, postmarked within 30 business days of the date of the originalaudit results letter.d. The appeal must include documentation supporting each claim line, including theclaim number, member name, date that the service occurred, service code, numberof units involved, monetary amount, and the rationale for the appeal for each item inquestion. Only specific documentation supporting provider disagreement with auditexceptions will be reviewed by the Provider Appeal Committee for considerationduring this appeal process.e. All documentation relevant to the audit will be forwarded to the Provider AppealCommittee and a decision will be rendered within 30 days of receiving all of theappeal information.f. The decision of the committee will be considered final and the provider will benotified in writing of the appeal decision.Community Care includes information about fraud and abuse concerns in member andprovider education materials. Along with information about how to identify suspectedfraud and abuse, Community Care encourages members and providers to reportsuspected fraud and abuse through the toll-free numbers that are provided to them.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 129