Billing Manual for Community Care Network Providers

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See the policy on Transition of Prior Consents and Authorizations for the completeprocedure.Community Care may use and disclose PHI in order to improve business operationsand services to members. PHI that has been de-identified and restricted may bereleased to business associates for activities such as, but not limited to: oversight,auditing, or improving Community Care’s daily operations (HIPAA 164.504(f)(2)). Priorto releasing such information, business associates must sign a Business AssociateAgreement. This agreement holds the business associate accountable for the PHI thatthey will receive. Included in the agreement is (HIPAA Section 164.512(i)):A description of the permitted uses and disclosures of the limited PHI by therecipient, consistent with the purposes outlined in his/her proposal or contract.The requirement to limit access to who may receive the data.The requirement that the business associate will not use or disclose this informationother than as permitted by the agreement or otherwise required by law.The requirement that the business associate will take appropriate safeguards toprevent the use or disclosure of the information. If the business associate becomesaware that the information was tampered with or released mistakenly they mustnotify Community Care. Community Care will give the business associate anopportunity to investigate and rectify the situation.The requirement that the business associate will ensure that any agents, including asubcontractor, to whom the business associate provides the limited information,agrees to the same restrictions and conditions that apply to the business associate.The expectation that the business associate will not try to re-identify the informationor contact members.An explanation that if the Secretary of Health and Human Services requests thisinformation in order to oversee if Community Care is compliant with HIPAAregulations, the business associate will release the information to the Secretary.The requirement that, once the information is no longer needed the businessassociate will destroy it or return it to Community Care in order for it to be destroyed.A clause allowing the business associate contract to be terminated at any time ifCommunity Care has reason to believe that the business associate has violated anyof the above.Community Care may disclose PHI that has been de-identified to business associatesfor business functions that have been contracted. Community Care requires thefollowing of the business associate contract (HIPAA Section 164.504(e)(ii)):The information given to them will not be used or further disclosed unless it isrequired or permitted by the contract or as required by the law (HIPAA Section164.504(e)(ii)(A)).He/She will take appropriate precautions with the information they are given (HIPAASection 164.504(e)(ii)(B)).In the event that someone discloses information he/she, will report the breach toCommunity Care as soon as they become aware of it (HIPAA SectionCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 188
164.504(e)(ii)(C)).He/She will ensure any additional agents, including subcontractors to whom thisinformation may become available, follow the same restriction and conditions thatapply to him/her (HIPAA Section 164.504(e)(ii)(D)).The member may access, amend, or have an accounting of the information that isreleased to a business associate.The information released by Community Care will be available if requested by theSecretary of Health and Human Services in order to track Community Care’scompliance with HIPAA (HIPAA Section 164.504(e)(ii)(H)).At the termination of the contract or when this information is no longer needed, thebusiness associate has the necessary means to destroy this information or have thisinformation returned to Community Care in order for it to be destroyed (HIPAASection 164.504(e)(ii)(I)).A business associate’s contract may be terminated at any time if we feel thebusiness associate has violated any of the above (HIPAA Section 164.504(e)(iii)).Community Care may disclose PHI about victims of abuse, neglect, or domesticviolence without an authorization to law enforcement officials or government agenciesby a representative using his/her professional judgment (HIPAA Section164.512(c)(1)). If Community Care releases such information, it will promptly inform themember that such a report has been made except when:Informing the member would put him/her in serious danger or harm.Community Care is unable to inform the member, in which case the personalrepresentative may be informed that Community Care released this information.However, if Community Care believes the personal representative is responsible forthe abuse, neglect, or other injury then he/she would not be notified.Community Care may disclose PHI without an authorization to a law enforcementofficial:When required by law for the purposes of, but not limited to, investigating acomplaint or civil or criminal charges (HIPAA Section 164.512(f)). The informationrequested must first be forwarded to Community Care legal counsel for review.In the event that the member has died, for the purposes of alerting the law. IfCommunity Care has a suspicion that such death may have resulted from criminalconduct (HIPAA Section 164.512(f)(4)).If there is evidence of criminal conduct that has occurred on our premises (HIPAASection 164.512(f)(5)).If the member (HIPAA Section 164.512(f)(6)) contacts Community Care about acrime (commission or nature of one), the location of such crime or the victim (s) ofsuch crime; and the identity, description, and location of the perpetrator of such acrime.In this latter instance, the Community Care representative will notify his/her directsupervisor of the situation, and will call 911 to report this information.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 189
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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
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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 184 and 185: Community Care extends all reasonab
Page 186 and 187: For research purposes.On behavioral
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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