Billing Manual for Community Care Network Providers

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“A self-determined and holistic journey that people undertake to heal and grow.Recovery is facilitated by relationships and environments that provide hope,empowerment, choices and opportunities that promote people reaching their fullpotential as individuals and community members.”It includes consumer choice, self-determination, and acceptance, and is designed toreach individuals and families at risk of crisis or disability; stimulate, facilitate, andsupport recovery for persons with behavioral health disorders; enable recovery; andpromote individual, family, and community health and well-being.To help Community Care representatives (including providers) understand andparticipate in Community Care’s vision, we share these definitions: Culture is the patterns of behavior that include communications, actions, customs,beliefs, values, and institutions of a social group. Cultural Identity includes, but is not limited to race, ethnicity, language, age, regionor country of origin, degree of acculturation, gender, socioeconomic class, religiousbeliefs, and gender. Cultural Awareness is the understanding that people are shaped by the social,linguistic, ethnic, and behavioral characteristics of the cultures to which they belongand that there are patterns of expressions, beliefs, values, and practices that can beshown to enable those providing behavioral health care to understand the diversityof people. Cultural Sensitivity is knowledge about the social, linguistic, ethnic, behavioral andinteractional characteristics of a group or population, how those behaviors andcharacteristics may influence a group’s worldview and the demonstration of thisknowledge through provider and organizational interactions and communications. Cultural Competence is the ability to systematically translate knowledge andunderstanding of the social, behavioral, and interactional differences of groups intoattitudes and practices of care, such as acknowledgment, inclusion, and helpfulnessthat promote the behavioral health and well-being of individuals, families, andcommunities.Cultural competence is an essential part of this vision. It benefits Community Care’snetwork of behavioral health providers by generating trust and maintaining credibilitywith members, agencies, and the community. Cultural competence demonstrates acommitment to eliminating barriers that prevent our agencies from meeting theirpotential and full responsibilities to their communities. That commitment is proventhrough effective policies and administration, effective frontline provision of services,and the evaluation of those services.Providers will be informed (through mailings, website articles, forums, and otherinteractions) about Community Care’s commitment to a culturally competent system ofservices provision, instructed on standards and performance indicators, providedexamples for demonstration of cultural awareness and sensitivity, given assistance andCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 16
esources and evaluated on their progress toward cultural competence. Providers’commitment is essential to our ongoing development of a responsive system of care.I.C. Overview of Quality ManagementThe Community Care quality management program is based on a philosophy thatemphasizes a systematic, organization-wide perspective that involves everyone. It isfocused on achieving satisfaction for both internal and external customers andimproving member outcomes within an organizational environment that seekscontinuous improvement of systems and processes.The foundation is good business ethics. Professional integrity and mutual respect aredefining characteristics of the quality management program philosophy.From its outset, Community Care recognized company-wide quality goals that havebeen integrated into all department activities. At its most fundamental level, qualitymanagement aims to sustain and improve the health status of members by measuringand improving performance of care and services within the healthcare delivery systemprocesses and structure. Community Care is committed to improving the health statusof the populations it serves and, by extension, the community. Our quality improvementprogram is designed with input from network practitioners and follows the guidelines ofall regulatory and oversight agencies including the Department of Health and theNational Committee for Quality Assurance (NCQA).Areas of focus include: Delivering high-value, culturally competent care that incorporates the special needsand preferences of members. Continuously improving the clinical care and service provided to members. Enhancing the community’s health status through behavioral health wellness andpreventive programs. Pursuing opportunities to improve the health status of members and target efforts tothe needs of the population. Ensuring that care and services are available and are provided to members in atimely manner, appropriate to the member’s needs and preferences. Ensuring that care and services are coordinated between providers and across alldelivery settings through the care management process. Establishing collegial relationships with providers to achieve superior clinical andcustomer service outcomes. Providing exceptional customer service. Continuously improving quality improvement processes by maintainingcomprehensive, current, and effective quality management policies and procedures. Analyzing performance data and identifying opportunities to improve performanceand outcomes.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 17
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 and 14: Non-Acute PartialHospitalizationNot
Page 15: I.A. Code of EthicsCommunity Care
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
Page 64 and 65: 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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