Billing Manual for Community Care Network Providers

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must verify that the member has signed an authorization to release such data orinformation to the employer. Community Care will require that the employer agree inwriting to protect all member identifiable data and information from being used in anydecisions affecting the member (HIPAA 164.504(h)(3)(iv)).Many requests from employers for data and information can be fulfilled withdata and information that are not member identifiable: In instances where an employer requests member identifiable information,Community Care will inquire as to the proposed use of the data and information andattempt to meet the need with data and information that are not member identifiable,for example aggregated data or information. In instances where member identifiable data or information is required, CommunityCare will ensure that an authorization for the release of information is signed by themember prior to releasing implicit data to the member’s employer. In all instances, Community Care only discloses the minimal information necessaryto accomplish the purpose of the disclosure.Handling of Practitioner Specific InformationCommunity Care considers practitioner specific data and information, including but notlimited to, that used for network development, credentialing, performance evaluation,quality assurance, quality improvement, compliance auditing and peer reviewconfidential to the extent permitted by law.A practitioner’s name, professional degree, status as the member of CommunityCare’s practitioner network, business address, business telephone number, andspecialty (ies) or self-identified areas of special interest are not consideredconfidential when disclosed for legitimate business purposes.Data and information related to a practitioner’s racial, cultural or ethnic background,age, religious affiliation, sexual orientation, and ability to communicate in languagesother than English, is confidential unless a practitioner explicitly authorizes to therelease of this information.Community Care’s credentialing and recredentialing applications request that suchinformation be supplied at the discretion of a practitioner.The credentialing and recredentialing applications state that if such information issupplied, Community Care may use and disclose only the minimum amount ofinformation to members or appropriate individuals for purposes of meeting a specificMember needs or requests when making referrals.Practitioner files are maintained in a locked room or locked file cabinet when not inuse by credentialing staff or the Credentialing Committee. Practitioner files stored inelectronic, magnetic, or optical format are protected with a secure password.Access to practitioner files is limited to the network management, compliance, andcredentialing staff and the Credentialing Committee.Practitioners may review the information in his/her file upon request except for anyinformation from the National Practitioner Data Bank (NPDB) and peer (professionaladvisor) review information. Review of NPDB information is prohibited by FederalCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 150
statute. Each practitioner is informed of the right to review information in his/her file throughthe cover letter in the application packages for initial credentialing andrecredentialing. A practitioner may obtain a copy of his/her file. The request must be in writing. Credentialing staff will send a copy of a practitioner’s file to him/her within 10business days of receipt of the written request for the file. This file when mailed willbe sealed in an envelope marked confidential. NPDB information is not included. Peer review information is not included. Practitioners are notified by the credentialing staff of any information obtained duringcredentialing or recredentialing activities that varies substantially from theinformation provided by the practitioner. Practitioners have the right to correct erroneous information. Practitioners may submit any corrections in writing or additional documents to theCredentialing Department. Credentialing staff will document any verbal information or corrections provided by apractitioner in the file including the date and signature of the individual who obtainsthe information.Informing Providers about ConfidentialityThe following policies and procedures are included in Community Care’s ProviderManual and updated as needed:General Confidentiality Provisions.Oversight of Confidentiality Practices.Collecting and Using Member Identifiable Information.Informing Members about Confidentiality.Ability to Give Informed Authorization.Member Access to Utilization Records.Disclosure of Information.Disclosure of Information to Employers.Handling of Practitioner Specific Information.Practitioner Office Confidentiality.Practitioner Office ConfidentialityMember identifiable data and information maintained in paper-based or removablecomputer storage media must be maintained under lock and key, either in lockedcabinets or in a locked area.Member-identifiable data and information includes, but is not limited to, medicalrecords, appointment books, patient reminder cards, correspondence, laboratoryCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 151
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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
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IV.E.3 Transition of Care to anothe
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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 146 and 147: Under some circumstances, it may be
Page 148 and 149: 164.504(e)(ii)(A)).They will take a
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
Page 196 and 197: • The name, or title, and the tel
Page 198 and 199: 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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