Billing Manual for Community Care Network Providers

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NameAddress (es)Zip CodeDiagnosis (es)Treatment DatesDate of BirthDate of DeathTelephone Number (s)Fax NumberElectronic Mail AddressSocial Security NumberUtilization Record ID NumberHealth Plan Beneficiary Number (s)Account Number (s)Certificate/License NumberDriver’s License NumberWeb Universal Resource Locators (URL’s)Any unique identifying number, characteristic, or code in which Community Carecreated that if external sources deciphered the code they could identify the Member.There are times when disclosures of protected health information are made on a routineand recurring basis, to providers for the purposes of treatment, payment, and healthcare operations (HIPAA Section 164.514(d) (3)). These disclosures are a vital part ofour daily performance and may not be restricted. The provider identification is verifiedby our caller ID system as well as by the provider supplying specific identifyinginformation pertaining to the member, e.g., member ID and Social Security Number.Community Care staff identifies themselves to providers with their names, titles, andspecific identifying information pertaining to the member. If at any time there is aquestion as to the identity of the caller, staff members are instructed to take the name ofthe caller, the facility that is calling, and a telephone number where the call can bereturned. The contact and telephone number are verified before the call back is madeand any information is divulged.While Community Care does not maintain a medical record, Community Care doeskeep a utilization record. Per HIPAA (Section 164.501) a designated record set whichCommunity Care refers to as a utilization record is – a group of records maintained byor for Community Care, used, in whole or in part, by Community Care to make decisionsabout the member or provider, which may contain the following but is not limited to:The medical and billing records about the member or provider.The enrollment, payment, claims adjudication, and case or medical managementrecord systems maintained by Community Care.In accordance with HIPAA (Section 164.524), the member may request to restrict thisinformation if desired. The member has the right to request at any time to restrict theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 178
collection, use, or disclosure of his/her protected health information. The member maywrite a letter to the privacy officer at Community Care, requesting to restrict thedisclosure of his/her protected health information. The letter must include what specificinformation the member wants restricted, the member’s signature, and it must be dated.The privacy officer will review the member’s request and will respond in 30 days inwriting if this information is on site. If the information that the member is requesting isnot on-site, Community Care will retrieve the information within 60 days.If needed, Community Care may extend the retrieval an additional 30 days provided thatthe member is sent a written letter with an explanation for the delay, and provide a datein which we will have this information. Community Care will only have one suchextension of time for each request. If the restriction of protected health is granted:The privacy officer will send a letter to the member informing him/her howCommunity Care will limit his/her information.The privacy officer will oversee the process to restrict the PHI.This granted request for restriction of PHI will be recorded in the Member Request toLimit Protected Health Information Log, which is maintained by the privacy officer orhis/her designee.The privacy officer will notify the manager of the file room to have the member’s filepulled.The privacy officer or his/her designee will place on the front of the member’sutilization record a sticker.The sticker will have in writing on it “RESTRICTED INFORMATION.”If this file is requested by an employee, the file room clerk must see the privacyofficer, or his/her designee, to receive permission to process the request this file.Once the employee is finished with this file and returns it to the file room, the fileclerk must alert the privacy officer or his/her designee that the file has beenreturned.The privacy officer will notify all necessary department managers of the member’srequest to limit his/her PHI.PsychConsult will contain an alert notifying staff that this particular member’srecords are restricted.If the Member’s request is denied the privacy officer will:Record in the Member Request to Limit Protected Health Information Log that therequest was denied.Send the member a letter within 30 days of the decision 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.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 179
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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
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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 176 and 177: Community Care has identified circu
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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