Billing Manual for Community Care Network Providers

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Community Care extends all reasonable effort to develop and maintain anaccurate and efficient system for member information.Having established such a system, Community Care reasonably relies on theabsence of information indicating that the member or parent of a minor has beenadjudicated incompetent and that a parent is not a minor’s legal representative.Verifying the accuracy of the absence of such information would place an undueburden on Community Care and in most instances would require a breach ofconfidentiality.When Community Care is informed that the member is unable to give specialauthorization for the release of information, Community Care will acceptauthorization from, and/or release records to, a representative legally authorizedto release or receive the member’s personal health information. CommunityCare requires written proof of the individual’s status as a legally authorizedrepresentative and that the status covers the area for which the authorization isbeing sought.Individuals capable of giving valid authorization for the release of memberidentifiable health information are also entitled to have access to suchinformation except as follows: parents or guardians of children age 14 years orover may not have access to the child’s health information without authorizationfrom the child.Member Access to Utilization Records/Protected Health InformationCommunity Care does not provide direct care or treatment to members.In the event that Community Care intends to become a direct provider of careand treatment, Community Care will develop policies and procedures thataddress:How members can access their medical records if permitted.A process whereby members may restrict, access, amend, or have an accounting oftheir medical files that are under Community Care’s control.In accordance with HIPAA (Section 164.524), the member may access his/herutilization record if desired. The member may request to view his/her utilizationrecord by writing a letter to the privacy officer at Community Care.The privacy officer reviews the member’s request and will respond within 30 days.If the information requested by the member is not on site, Community Care willretrieve the information within 60 days.If needed Community Care may extend the retrieval an additional 30 days providedthat the member is sent a written statement with the reasons for delay and a date bywhich we will have the information.Community Care will only have one such extension of time for the request.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 184
If a member is granted access to review his/her records:The privacy officer will oversee the process to view the PHI.This granted request to review records will be recorded in the Member Request toReview Protected Health Information Log, which will be maintained by the privacyofficer or his/her designee.The privacy officer and or his/her designee will discuss with the member:• The format in which this information will be presented• How and where this information will be viewed (the member may choose toreview his/her records at Community Care or have the information mailed in anenvelope marked confidential to an address that they have specified).• If the member would like a summary of the information, or copies.• That a nominal fee may be charged by Community Care for postage, copying, orpreparation of the information (including the labor of copying the informationrequested).If Community Care is unable to accommodate the member’s request to view thisinformation, the Privacy Officer will send the member a letter describing:The decision.The reason for the denial.A description of the appeals process.The right to file an appeal along with the process for filing.The name, or title, and the telephone number of the contact person for the next step.Disclosure of InformationExcept as described in the procedures in Collecting and Using Member IdentifiableInformation, Community Care requests authorization from the member or the member’slegally authorized representative prior to disclosing the member’s PHI to externalsources.Community Care will only disclose PHI in accordance with the most restrictiveconsent, authorization or other written legal permission from the member, unlessotherwise specified by the member (HIPAA 164.506(e)).The member or the member’s legally authorized representative has the right to denythe request to release member identifiable information without any consequences tothe member or the member’s coverage.If member identifiable data and information are to be disclosed for purposes other thanthose described in the policies cited in paragraph 1, above, the authorization of themember or member’s legally authorized representative is required (HIPAA Section164.504). This includes, but is not limited to information:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 185
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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
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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,
Page 134 and 135: Confidential data and information s
Page 136 and 137: The medical director or his/her des
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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
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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 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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