Billing Manual for Community Care Network Providers

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For research purposes.On behavioral health signs, symptoms, diagnoses, or treatment from a primary carephysician or other clinician not providing behavioral health care.That could result in a member being contacted by another organization for marketingpurposes.There may be times when Community Care needs to disclose information about themember without receiving informed authorization. These situations include, but arenot limited to (HIPAA Section 164.506(a) (3) (I)):Emergency situations where the member’s life or other lives may be at risk.Community Care may disclose information for the purpose of identification andlocation of the member with or without his/her authorization in response to a lawenforcement official’s request for information to identify, or locate a suspect, fugitive,material witness, or missing person. The following information may be releasedunder these circumstances (HIPAA 164.512(f)(2)):• Name and address.• Date and place of birth.• Social Security Number.• Date and time of treatment.• Date and time of death, if applicable.• Any description of distinguishing physical characteristics (height, weight, gender,race, hair/eye color, and any distinguishing traits - scars, tattoos, etc).When there is a substantial barrier to communication with the member andCommunity Care’s representative, using his/her professional judgment, believes theindividual’s consent to receive treatment is clearly inferred.When authorized by Community Care’s legal counsel to meet the requirements offederal, state, and local law.For public health activities as required by law (HIPAA 164.512(b)(i)):• To prevent or control disease, injury, or disability.• To report births and deaths.• To report child abuse or neglect.• To report reactions to medications or problems with products.• To notify people of product recalls, repairs, or replacements.• To notify a person who may have been exposed to a disease or condition.• To notify the appropriate government authority if we believe the member hasbeen the victim of abuse, neglect, or domestic violence.• Disclosures to federal, state, or county agencies that oversee Community Care,such as governmental monitoring of the health care system, medical assistance,government programs, and compliance with civil rights laws.• In regards to the care or payment related to the member’s health care (HIPAASection 164.510(b)).Under some circumstances, it may be necessary to obtain authorization verbally. Theuse of a verbal authorization should be approved in advance by Community Care’s legalcounsel or, if circumstances indicate a need for a rapid decision then by a member ofCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 186
Community Care’s senior management team. If approved, two representatives ofCommunity Care must witness the entire process of obtaining verbal authorization torelease information.Community Care considers an authorization to release information to be valid only if(HIPAA 164.508(c)) :It provides the name of the person(s) providing the information.It is in a language the member can understand.There is a purpose for the release.The specific information to be released (dates of treatment, and the exact type ofinformation to be released, i.e., mental health, drug and alcohol) is described.The member’s full name at the time of treatment and correct identifying information,e.g., date of birth and Social Security Number.The individual or entity authorized to receive the information is described.The expiration date of the authorization.The signature of the member or the member’s legally authorized representative (ifthe authorization is signed by a personal representative of the individual, adescription of such representative’s authority to act for the individual).The release is obtained in a manner that complies with applicable law andregulations.There is a statement that treatment will not be affected if the member or member’srepresentative refuses to sign the authorization.There is a witness signature.There is a date of expiration for the authorization.There is a written statement on the authorization form that once this information isreleased to the recipient, this information may be subjected to re-disclosure by therecipient and no longer protected by this rule.There is a statement on the authorization form that if this information is used ordisclosed pursuant to the authorization, it may be subject to re-disclosure by therecipient and no longer be protected by this rule.There is a statement that the individual has the right to revoke this authorization inwriting, including the exceptions to the right to revoke, and a description of theprocess for the individual to revoke the authorization.Community Care will not release the information unless the form is completed.Prior to releasing information of previously signed authorization to releaseinformation, Community Care will review all authorization forms that are still in effectto ensure that they are compliant with HIPAA regulations.If a previously signed authorization is compliant with HIPAA regulations CommunityCare will continue to release the information until the authorization expires.If the authorization is not HIPAA compliant, then Community Care will contact themember within 60 days to obtain a newly signed authorization that conforms toHIPAA regulations.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 187
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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,
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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 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 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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