Billing Manual for Community Care Network Providers

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“Statement of Confidentiality” AgreementMember and Provider InformationI understand and agree that in the performance of the specific assigned duties forCommunity Care, I must maintain and safeguard the confidentiality of all personallyidentifiable member, practitioner, or provider information. This information must be keptstrictly confidential and must never be disclosed, other than for appropriate businesspurposes, and only to those persons who need to know.General InformationI understand that, in addition to the foregoing, there is a wide range of other sensitiveproprietary and business information including, but not limited to, Community Careplans and projects; financial and operating details; prospective and past transactionswith customers, suppliers and other companies; and compilations of business data. Iunderstand that every precaution should be exercised to preserve the confidentiality ofall such information until specifically released in writing or made public by CommunityCare officials.Because of my affiliation with Community Care, I know that I have access to sensitiveand confidential data and information and by signing this Statement I agree not toaccess data and information from source (s) that are not needed to perform my jobduties.I expressly agree that I will not use information for my own benefit nor disclose it toothers, except as properly authorized and for appropriate business purposes.I also agree that when my work with Community Care is ended for any reason, I willpromptly deliver to Community Care all correspondence, reports, memoranda, records,manuals, notes, drawings, data, software, and other materials belonging to CommunityCare and pertaining to its business, including copies of any of the foregoing materials,which may be in my possession or under my control.When faced with an inquiry from an outside source, whether at work or away from work,or whenever I have any doubts about disclosure of information, I agree that I willdisclose nothing and ask my Director/Supervisor or the Privacy Officer at CommunityCare for direction.Signature/DateWitness/DateCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 170
POLICYCommunity Care, our staff and agents, shall protect the confidentiality of all confidentialdata and information to which they have access. “Confidential” information is defined asany information by which the member could be identified. The purpose of this policy isto assure that all data and information obtained by Community Care, and ourrepresentatives, are maintained and used with the degree of confidentiality and securitythat the data and information warrant.PROCEDUREGeneral Confidentiality ProvisionsCommunity Care has designated the privacy officer to oversee company policies andprocedures regarding confidentiality and privacy. The specific functions for which theprivacy officer is responsible include but are not limited to:Annual review of all confidentiality policies.Annual training of Community Care employees on confidentiality.Follow-up to concerns of members or providers regarding confidentiality.The Compliance Department will assist the privacy officer with these responsibilities asrequired and requested.Community Care employees, staff, and volunteers are required to sign CommunityCare’s “Statement of Confidentiality” agreeing to be bound by strict confidentialitypolicies and procedures, including all federal and state laws, and the Health InsurancePortability and Accountability Act of 1996 (HIPAA). Signed “Statements ofConfidentiality” are maintained by Community Care’s Compliance Department.Community Care business associates potentially having access to confidentialinformation are required to sign Community Care’s “Statement of Confidentiality”agreeing to be bound by Community Care’s strict confidentiality policies and proceduresor must conform to equivalent provisions as determined by Community Care staff orlegal counsel.Breach of the “Statement of Confidentiality” or equivalent is grounds forimmediate termination.When Community Care becomes aware of a breach in confidentiality:The privacy officer will alert senior management of the breach.An investigation regarding the breach of the member’s (or provider’s) confidentialitywill be conducted by, or under the direction of, the privacy officer.All necessary staff will be interviewed.Any physical material involved will be reviewed.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 171
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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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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
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 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 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
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: ___________________________________
Page 208 and 209: APPENDIX C.1. Priority PopulationsM
Page 210 and 211: Second priority is associated with
Page 212 and 213: 3. Secondary Data - OMHSAS will dev
Page 214 and 215: BEHAVIORAL HEALTH MANAGED CARE ORGA
Page 216 and 217: APPENDIX E.1. Companion Guide for N
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Billing Manual for Community Care Network Providers

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