Billing Manual for Community Care Network Providers

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Community Care has identified circumstances necessitating special protection ofMember-identifiable data and information as described in the procedure on Handling ofMember Identifiable Information. Community Care acknowledges that additionalcircumstances necessitating such special protection may also arise (HIPAA 164.522).All requests for special protection of Member-identifiable data and information notaddressed in the policy referenced above shall be referred to the Privacy Officer.The privacy officer will consider the request and determine whether the requestshould or should not be honored.If the privacy officer determines that the request should be honored he/she will sendthe member a letter within 30 days including:• Notify the requestor of his/her decision.• Determine the mechanism to adhere to the request.• Update the procedure on Internal Handling of Member Identifiable information toreflect the addition.If the privacy officer determines that the request should not be honored he/she willsend the member a letter including:• The decision.• The reason for the denial.• A description of the appeals process.• The right to, and process for, filing an appeal.• The name, or title, and the telephone number of the contact person for the nextstep.All member and practitioner concerns regarding confidentiality shall be logged ascomplaints and processed through Community Care’s complaint and appeals process(HIPAA Section 164.530(a)(1)(ii)).The privacy officer will be notified by the Complaint and Grievance Departmentabout complaints regarding privacy or confidentiality.The privacy officer or his/her designee will maintain a log with all complaints orgrievances dealing with confidentiality and privacy.The privacy officer or his/her designee will work with the Complaint and GrievanceDepartment on resolving complaints dealing with confidentiality and privacy.The privacy officer is responsible for reviewing requests for access to memberidentifiable data and information from all sources (internal, external, and businessassociates) and may enlist the cooperation of the Compliance Department andmedical director as appropriate.In determining the time frame within which to conduct such a review, the privacy officeror medical director if appropriate, will consider the potential benefit to the membershipfrom the requested access to data and information. For example, health outcomes maybe improved if access is granted to information on diagnosis so that a healthmanagement or preventive health program can be implemented.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 176
In the event that Community Care would participate in a research study, the medicaldirector in collaboration with the privacy officer is responsible for reviewing all requeststo access confidential data associated with a research project.The medical director or his/her designee will request a description of the purpose forthe requested information from the business associate.All requests for de-identified information will be recorded in the Request for DeidentifiedInformation Log.Each request will be reviewed individually.For each request, Community Care will determine how this information will be deidentified.If Community Care is able to reduce the amount of information requested while stillmeeting a business associate’s request, it will do so.Community Care will develop a code to de-identify this information (HIPAA164.514(c). This code will be unique with each request for information. This code willnot be released to the business associate, and each code will be kept in the Requestfor De-identified Information Log. Only the medical director or his/her designee willhave access to this log.The medical director will present the request for information to the OutcomesCommittee for final approval.When the privacy officer receives the decision from the Outcomes Committee; theywill notify the requestor in writing, confirming if the requested information will bereleased, the manner in which it will be released, and how the information will be deidentified.If Community Care did not grant the request for information, a briefexplanation of the reason will be given instead.Once this has all occurred, the member will be contacted by Community Care to seeif he/she would like to participate in any active clinical research activity. CommunityCare is required to receive the member’s authorization prior to the release of anyinformation to a business associate for research purposes. If the member agrees toparticipate in the study and once the signed authorization is received from themember, the information will be released to the business associate conducting theresearch.If the member declines to take part of this study, his/her coverage will not beterminated with his/her refusal to participate.Collecting and Using Member Identifiable InformationCommunity Care collects and uses only the minimum necessary member identifiabledata and information routinely in the performance of our work. Community Careemployees are required to sign a “Statement of Confidentiality” when hired, agreeing tobe bound by Community Care’s strict confidentiality policies and procedures and allfederal and state laws.Community Care considers the following as member identifiable information, but it is notlimited to that listed below. This information used alone or in any combination mayidentify the member (HIPAA 164.512(b)(2)(I)):Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 177
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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
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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
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 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 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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