Billing Manual for Community Care Network Providers

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Policy on Release of Information Related to the Treatment of Minors.Policy on Release of Information Related to Mental Health Treatment.Policy on Release of Information Related to Drug and Alcohol Dependency andTreatment.Policy on Community Care Staff Having Knowledge of or a Relationship with theMember.PROCEDURESConfidentiality: Terms and Disclosure PolicyCategories of Information - Community Care’s legal obligations with respect todifferent types of information vary. For the purposes of this policy, information isgrouped into the following categories:Claims Information - The member identifiable information, both medical and nonmedical,submitted by the member or the health care provider to Community Care on aclaim form for the purpose of obtaining payment for medical services. CLAIMSINFORMATION includes information submitted to complete an incomplete claim form,but does not include medical records or information generated by Community Care inconnection with utilization review, quality assurance, case management, complianceaudits, or other managed care activities.Medical Records - All member identifiable information within the member’s medical fileas documented by the attending physician or other medical professional and which iscustomarily held by the attending physician or provider hospital. Medical records maybe sent (following HIPAA guidelines) to Community Care in connection with utilization,compliance, or quality assurance activities, or may be furnished as supportingdocumentation to claims information. In Pennsylvania, the original medical record is theproperty of the provider.Utilization Record - A group of records maintained by or for Community Care, used, inwhole or in part, or for Community Care to make decisions about the member orprovider that may contain the following but is not limited to:The medical and billing records about the member or providerThe enrollment, payment, claims adjudication, and case or medical managementrecord systems maintained by Community Care.Aggregate Claim Information (“ACI”) - means all non-identifiable member informationconcerning medical claims.Member File Information - means the member’s enrollment application, records ofcommunications between Community Care and the member, records of administrativecorrespondence, such as referral forms, between practitioners and Community CareCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 158
concerning the member and the like. This information is typically maintained in what iscalled the “utilization record”.Community Care Proprietary Information- means information about the wayCommunity Care conducts business, including but not limited to trade secrets,confidential financial information, provider contract information, business associateagreements, and utilization management (UM) and quality management (QM)methodology created and utilized by Community Care. Community Care proprietaryinformation also includes usual and customary database information and specificcharge information. Descriptions of Community Care business practices routinelyincluded in responses to Requests for Proposals or otherwise made available to thepublic are not proprietary information. Director level personnel, in consultation withlegal services, are responsible for determining whether other information is proprietary.Patient Identifiable Claim Information – see “CLAIMS INFORMATION”Aggregate Claim Information (ACI) and Community Care Non-Medical ProprietaryInformation – Per State law Community Care is prohibited from releasing any claimsinformation or status to HealthChoices members.Confidentiality: Compliance with State and Federal LawsCommunity Care complies with all state and federal laws and regulations pertaining tothe disclosure of confidential member information and to assure that such confidentialinformation is not released without proper documentation, appropriate authorization,and in accordance with HIPAA regulations to contract holders and their minions.Community Care publishes and distributes a DPW approved Member Handbook to allMedical Assistance members. This handbook describes confidentiality protectionsincluding explanation of access to the member’s clinical records by oversight agenciesand access to records for quality and utilization oversight purposes. The MemberHandbook also advises members about the appropriate release of information formsneeded to send information in their utilization record to other providers of health care.In addition, Notice of Privacy statements are sent to all members in accordance withHIPAA privacy regulations.Notice to Accompany Information Released Pursuant to Written Authorization forDisclosureEach disclosure made to a third party with the member’s written authorization must beaccompanied by the following written statement:This information has been disclosed to you from records whose confidentiality isprotected by federal and Pennsylvania law including the Health Insurance Portabilityand Accountability Act of 1996. These laws and regulations prohibit you from makingany further disclosure of this information unless further disclosure is expressly permittedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 159
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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
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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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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 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 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
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Page 172 and 173: Findings will be reported to senior
Page 174 and 175: information and by signing this sta
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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
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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
Page 200 and 201: Orientation and ongoing provider ed
Page 202 and 203: CONSENT FOR RELEASE OF INFORMATIONM
Page 204 and 205: Authorization for the Release of Dr
Page 206 and 207: ___________________________________
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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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