Billing Manual for Community Care Network Providers

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Under some circumstances, it may be necessary to obtain authorization verbally. Theuse of a verbal authorization should be approved in advance by Community Care’s legalcounsel or, if circumstances indicate a need for a rapid decision then by the member ofCommunity Care’s senior management team. If approved, two representatives ofCommunity Care must witness the entire process of obtaining verbal authorization torelease information.Community Care considers an authorization to release information to be valid only if(HIPAA 164.508(c)):It provides the name of the person (s) providing the information.It is in a language the member can understand.There is a purpose for the release.The specific information to be released (dates of treatment, and the exact type ofinformation to be released, i.e., mental health, drug and alcohol) is described.The member’s full name at the time of treatment and correct identifying information,e.g., date of birth and Social Security Number.The individual or entity authorized to receive the information is described.The expiration date of the authorization.The signature of the member or the member’s legally authorized representative (Ifthe authorization is signed by a personal representative of the individual, adescription of such representative’s authority to act for the individual).The release is obtained in a manner that complies with applicable law andregulations.There is a statement that treatment will not be affected if the member or member’srepresentative refuses to sign the authorization.There is a witness signature.There is a date of expiration for the authorization.There is a written statement on the authorization form that once this information isreleased to the recipient, this information may be subjected to re-disclosure by therecipient and no longer protected by this rule.There is a statement on the authorization form that if this information is used ordisclosed pursuant to the authorization, it may be subject to re-disclosure by therecipient and no longer be protected by this rule.There is a statement that the individual has the right to revoke this authorization inwriting, including the exceptions to the right to revoke, and a description of theprocess for the individual to revoke the authorization.Community Care will not release the information unless the form is completed.Prior to releasing information of previously signed authorization to releaseinformation, Community Care will review all authorization forms that are still in effectto ensure that they are compliant with HIPAA regulations.If a previously signed authorization is compliant with HIPAA regulations CommunityCare will continue to release the information until the authorization expires.If the authorization is not HIPAA compliant, then Community Care will contact themember within 60 days to obtain a newly signed authorization that conforms toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 146
HIPAA regulations.See the policy on Transition of Prior Consents and Authorizations for the completeprocedure.Community Care may use and disclose protected health information in order to improvebusiness operations and services to members. Protected health information that hadbeen de-identified and restricted may be released to business associates for activitiessuch as, but not limited to: oversight, auditing, or improving Community Care’s dailyoperations (HIPAA 164.504(f)(2)). Prior to releasing such information, businessassociates must sign a Business Associate Agreement. This agreement holds thebusiness associate accountable for the protected health information that they willreceive. Included in the agreement is (HIPAA Section 164.512(i)):A description of the permitted uses and disclosures of the limited protected healthinformation by the recipient, consistent with the purposes outlined in his/her proposalor contract.The requirement to limit access to who may receive the data.The requirement that the business associate will not use or disclose this informationother than as permitted by the agreement or otherwise required by law.The requirement that the business associate will take appropriate safeguards toprevent the use or disclosure of the information. If the business associate becomesaware that the information was tampered with or released mistakenly they mustnotify Community Care. Community Care will give the business associate anopportunity to investigate and rectify the situation.The requirement that the business associate will ensure that any agents, including asubcontractor, to whom the business associate provides the limited information,agrees to the same restrictions and conditions that apply to the business associate.The expectation that the business associate will not try to re-identify the informationor contact members.An explanation that if the Secretary of Health and Human Services requests thisinformation in order to oversee if Community Care is compliant with HIPAAregulations, the business associate will release the information to the Secretary.The requirement that, once the information is no longer needed the businessassociate will destroy it or return it to Community Care in order for it to be destroyed.A clause allowing the business associate contract to be terminated at any time ifCommunity Care has reason to believe that the business associate has violated anyof the above.Community Care may disclose protected health information that has been de-identifiedto Business associates for business functions that have been contracted. CommunityCare requires the following of the Business associate contract (HIPAA Section164.504(e)(ii)):The information given to them will not be used or further disclosed unless it isrequired or permitted by the contract or as required by the law (HIPAA SectionCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 147
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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
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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
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 122 and 123: C/FST: Consumer/Family Satisfaction
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 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”
Page 172 and 173: Findings will be reported to senior
Page 174 and 175: information and by signing this sta
Page 176 and 177: Community Care has identified circu
Page 178 and 179: NameAddress (es)Zip CodeDiagnosis (
Page 180 and 181: Community Care has the right to den
Page 182 and 183: Member identifiable information may
Page 184 and 185: Community Care extends all reasonab
Page 186 and 187: For research purposes.On behavioral
Page 188 and 189: See the policy on Transition of Pri
Page 190 and 191: Community Care does not collect inf
Page 192 and 193: The request must be in writing. Cre
Page 194 and 195: 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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