Billing Manual for Community Care Network Providers

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I. About Community Care Behavioral Health OrganizationCommunity Care is a federally tax-exempt Pennsylvania nonprofit and 501 (c)(3)behavioral health managed care organization (BH-MCO). We are subsidiary of UPMCand part of the UPMC Insurance Services Division.Licensed as a Pennsylvania risk-assuming PPO by the Pennsylvania InsuranceDepartment, Community Care manages behavioral health services for MedicalAssistance beneficiaries who live in the counties served by Community Care. Thisincludes members of the HealthChoices program in each of the regions, Southwest,Southeast, Capital-Lehigh, Northeast, and North Central (State and County options).Community Care contracts with providers (individual or group practitioners, or facilitiesor organizations) to offer diverse behavioral health (mental health and chemicaldependency) services to HealthChoices members.For the success of our partnerships with members, providers, and the communities weserve, as well as for the achievement of our goals, Community Care relies on the strongcommitment of all parties involved to conduct business lawfully and ethically.Community Care’s code of ethics is embodied in our mission statement, statement ofvalues, and code of conduct.These documents guide our interactions with all of our partners, stakeholders and eachother. Consistent with our code of ethics, Community Care has developed qualitymanagement programs, policies, and procedures to ensure compliance with legal,regulatory, and professional requirements.The following sections describe Community Care’s ethical framework and processes indetail:A. Code of EthicsB. Cultural Competency VisionC. Overview of Quality ManagementD. Compliance with Fraud and Abuse ReportingE. Care Management TeamCall the Provider Line at 1-888-251-2224 with questions about Community Care’sethical framework or other material in this manual.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 14
I.A. Code of EthicsCommunity Care’s code of ethics includes our Mission Statement as well as thefollowing statement of values.Statement of ValuesCommunity Care holds the following values: Maintain member health and well-being as our highest priority. Be responsive to the needs of all members. Serve as a vital resource and partner for the region and communities in which wework. Value member satisfaction among our highest priorities and strive to ensure acompassionate, member-centered environment. Use professional ethics and integrity, which we believe are vital in making soundbusiness decisions. Be accountable to the citizens of our regions in all of our work. Commit to a continuous quality improvement process that focuses on the highestlevel of customer satisfaction possible. Facilitate improvements in access to care and to provide optimal value for the dollarsavailable. Link assessments and outcomes to the decision-making process by means of thelatest clinical and information technology. Provide a culturally competent workplace that encourages employee growth andpromotes employee satisfaction. Appreciate the diversity of our members, families, communities, providers, and staff. Build on the strengths of members, families, and communities by encouragingmembers and their families to participate at all levels of nationally recognizededucation and prevention programs. Respect and uphold the traditions of the communities of which we are a part.I.B. Cultural Competency VisionIn 2000, Community Care developed the following Cultural Competency statement, withinput from a group of network providers, community representatives, and oversightentities.Our vision for an effective and accessible behavioral health system of care leads withhigh-quality services that improve the health and well-being of our community. Our goalis to offer a system, ultimately free of barriers to obtaining services, comprised ofintegrated, balanced, and responsive mental health and substance abuse care. It isbased on the Pennsylvania Call for Change: toward a Recovery-Oriented Mental HealthService System, which defines “recovery” as:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 15
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 and 12: Functional Familytherapy (FFT)Multi
Page 13: Non-Acute PartialHospitalizationNot
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
Page 62 and 63: 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
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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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