Billing Manual for Community Care Network Providers

Community Care has the right to deny any request made by the member:That will interrupt daily operations to carry out treatment, payment, and health careoperations.If there is information subjected to the Clinical Laboratory ImprovementsAmendment of 1988, 42 U.S.C. 263a, to the extent the provision of access to theindividual would be prohibited by law: or Exempt from the Clinical LaboratoryImprovements Amendment of 1988, pursuant to 42 CFR 493.3(a)(2) (HIPAA164.524).If the information was compiled for a civil, criminal, or administrative action orproceeding.If the information involves the member currently in a correctional institution.If the member’s records are subject to the Privacy Act, 5 U.S.C. 552a, the membermay be denied the right to restrict or limit the use of his/her information under thisact.The member has the right to have his/her denial reviewed by a licensed health careprofessional who was not part of the original decision to deny. The member must write aletter to Community Care’s privacy officer requesting that his/her denial be reviewed.Community Care has designated our medical director to be the licensed health careprofessional to review this request. Community Care’s medical director must determinein a reasonable time, whether or not to grant or deny the member’s access requestbased on the above. A letter must be sent to the member with the medical director’sdecision.If the medical director’s decision is to grant the member’s request to the restriction thenproceed as above. If the opinion of the medical director is still to deny the request, aletter with this decision must be sent to the member including the reason for the denial,and an explanation of Community Care’s complaint and grievance process, includingthe name, or title, and the telephone number of the contact person for the next step.At any time the member may lift the restriction of his/her PHI by writing a letter toCommunity Care’s privacy officer requesting the restriction be lifted. Community Careprovides to members the Notice of Privacy, which describes the uses and disclosures ofPHI. The Notice of Privacy is sent to all members.Community Care uses the following methods to notify subscribers of Community Care’sroutine collection and use of member identifiable information:When Community Care is responsible for managing the enrollment process,subscribers are notified in writing at the time of enrollment of Community Care’sroutine collection and use of member identifiable information.In most instances, Community Care is not responsible for managing the enrollmentprocess. To ensure that all subscribers are notified of Community Care’s routinecollection and use of member identifiable information, some of the followingmechanisms are used:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 180