Billing Manual for Community Care Network Providers

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High-quality culturally competent health care and responsive customer services areprovided to all members. This philosophy is consistent with principles of continuousquality improvement as articulated by Deming, Juran, and others.Community Care views quality as an integrated company responsibility (promoted byspecific indicators facilitated by the Quality Management Department). CommunityCare's Board of Directors, management, departments, committees, oversight entities,providers, and community representatives all participate in quality improvementactivities.Community Care believes that input from appropriate committees, members, providers,and other stakeholders must be solicited on an ongoing basis in order for our qualityefforts to be successful.The philosophy stresses the importance of staff to achieve success. Teams ofindividuals are responsible for monitoring customer satisfaction and improvingperformance. Creativity and innovation within the scope of work are encouraged toensure customer satisfaction and exceed client and member expectations. Staff issupported in efforts to continually improve performance. Community Care views staff asthe solution to problems, not the cause. Community Care holds that the root causes ofsub-optimal performance, problems, or variation in a process are usually related to thesystem or process itself and not to staff.Community Care will share information with network providers about our: Quality improvement program, including goals, processes, and outcomes as relatedto care and service. Efforts to measure the availability of practitioners, facilities, and treatment programsand actions taken to improve availability. Efforts to measure the accessibility of care and service for members and actionstaken to improve accessibility. Overall findings of member satisfaction activities (such as the annual MemberSatisfaction Survey), including what we do to improve member satisfaction. Clinical practice guidelines and processes that measure guideline adherence. Expectations for exchange of information with primary care physicians (PCPs) andwithin the behavioral health continuum to facilitate continuity and coordination ofcare. Medical necessity criteria, including how to view or obtain a copy. Availability of and process for contacting the appropriate Community Care peerreviewer to discuss utilization management decisions. Description of the availability of an independent external appeals process forutilization management decisions made by Community Care. Policy prohibiting financial incentives for utilization management decision-makers. Member rights and responsibilities statement.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 18
Confidentiality policies including our routine uses and disclosures of enrollees’protected health information (PHI), enrollees’ rights to approve the release of PHInot covered by the routine consent, and access to the enrollees’ medical records.Preventive behavioral health programs including how successful these programshave been.Treatment record policies regarding confidentiality of treatment records,documentation standards, systems for organization of treatment records, standardsfor availability of treatment records at the practice site, and performance goals.If you would like more information regarding our quality improvement program, contactus at 1-888-251-2224. We will provide you with a description of the program and anupdate on our progress toward meeting our goals.If you have any suggestions for improving our quality improvement program or if youhave any questions about this information, please contact us:Community Care Behavioral Health Organization112 Washington PlaceOne Chatham Center, Suite 700Pittsburgh, PA 15219I.C.1. Quality Improvement MethodologyCommunity Care uses many processes in our quality management activities. A clearunderstanding of processes and knowledge of the reason for performance levels areessential to the quality management program. In order to understand performance, theinterdependent processes must be clear. Processes are related both hierarchically andin a matrix with many interrelationships. Until performance is measured using a rigorousmethodology, the actual state is unknown. Once a baseline is established, performancecan be understood in quantifiable terms. It is either out of control, in control but notwithin limits, or in control and within limits. Continuous improvement aims at havingperformance consistently at optimal achievable levels.Measurement with disciplined rigorous methodology is a principle strategy of the qualitymanagement program. This structured, disciplined operating orientation focuses onlong-term continuous improvement, recognizing that there are no quick fixes. Decisionsare based on fact and actual performance data, not opinions and anecdotal evidence.Quantitative methods are the foundation of the information used in making decisions.Measurement and performance data are fundamental to the quality managementprogram.The improvement system is continuous and consistent throughout the organization. Thecontinuous improvement system employs methodology for problem-solving, actionplanning, and performance improvement. The most commonly used problem-solvingmethodology is the “plan, do, check, act” method (the Shewhard-Deming cycle).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 19
Page 5 and 6: APPENDIX A.2. Confidentiality 130AP
Page 7 and 8: Clinical Fax by County:Adams 1-866-
Page 9 and 10: Outpatient Therapy 1MD OutpatientMe
Page 11 and 12: Functional Familytherapy (FFT)Multi
Page 13 and 14: Non-Acute PartialHospitalizationNot
Page 15 and 16: I.A. Code of EthicsCommunity Care
Page 17: esources and evaluated on their pro
Page 21 and 22: Within 30 minutes for urban areas.W
Page 23 and 24: I.E. Care Management Team“Advocat
Page 25 and 26: In order to serve special populatio
Page 27 and 28: Psychiatric Rehabilitation Clubhous
Page 29 and 30: always be considered in light of th
Page 31 and 32: Tell their provider everything they
Page 33 and 34: and calls received on the programs
Page 35 and 36: II.D.1e EvaluationIndividuals parti
Page 37 and 38: II.D.2b GoalsThe goals of Community
Page 39 and 40: II.D.3 Providers’ Role in the Pre
Page 41 and 42: Community Care has a total of 30 ca
Page 43 and 44: Department of Health and provide in
Page 45 and 46: An explanation of the grievance pro
Page 47 and 48: Upon request, the member will be as
Page 54 and 55: Notices must be in alternate format
Page 56 and 57: Community Care is a party to the he
Page 58 and 59: The following sections provide info
Page 60 and 61: members, practitioners are asked to
Page 62 and 63: Accreditation of Healthcare Organiz
Page 64 and 65: III.B.4 Facility ReassessmentFacili
Page 66 and 67: 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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The privacy officer will review the
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collection and use of member identi
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Protection of information disclosed
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If a member is granted access to re
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Under some circumstances, it may be
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164.504(e)(ii)(A)).They will take a
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must verify that the member has sig
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esults, billing records, and treatm
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equestor destroy the information, o
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The member has the right to request
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Policy on Release of Information Re
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y the written authorization of the
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If minor consents to treatment or c
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Current patients or clients or the
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If the client has given written aut
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Confidentiality policies pursuant t
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“Statement of Confidentiality”
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Findings will be reported to senior
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information and by signing this sta
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Community Care has identified circu
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NameAddress (es)Zip CodeDiagnosis (
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Community Care has the right to den
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Member identifiable information may
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Community Care extends all reasonab
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For research purposes.On behavioral
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See the policy on Transition of Pri
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Community Care does not collect inf
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The request must be in writing. Cre
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All statements to the media includi
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• The name, or title, and the tel
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APPENDIX A.4. Significant Member In
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Orientation and ongoing provider ed
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CONSENT FOR RELEASE OF INFORMATIONM
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Authorization for the Release of Dr
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___________________________________
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APPENDIX C.1. Priority PopulationsM
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Second priority is associated with
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3. Secondary Data - OMHSAS will dev
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BEHAVIORAL HEALTH MANAGED CARE ORGA
Page 216 and 217:
APPENDIX E.1. Companion Guide for N
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