Billing Manual for Community Care Network Providers

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• The name, or title, and the telephone number of the contact person for the nextstep.The member has the right to request in writing that Community Care attach astatement to all future releases such as “the member requested this information beamended and Community Care denied the request.”The privacy officer or his/her designee will record in the Member Right to AmendProtected Health Information Log that the member requested a statement similar tothe one above be attached to all future releases of information.The privacy officer or his/her designee will notify the manager of the file room tohave this member’s file pulled.A sticker will be placed on the front of the member’s utilization record that says:“SEE PRIVACY OFFICER BEFORE ANY INFORMATION IS RELEASED TOOUTSIDE SOURCES.” The privacy officer will need to see the information that isrequested before it is sent to ensure that the statement that the member requestedis included with the information.The privacy officer or his/her designee will also write a brief statement to be includedin the member’s file that the member requested to amend his/her PHI was denied.The member may also request that this statement be included with all futureinformation to be released.If the information the member is requesting to be amended is not the property ofCommunity Care, the member will be referred to the originator of the documents.If the originator of the PHI is unable to act on the request (for example, a practitionerwho is no longer in practice), and Community Care’s privacy officer feels that themember’s written request is legitimate, Community Care will amend the information inour possession (HIPAA 164.526(a)(2)(i)).Right to an Accounting of Disclosures of Protected Health InformationThe member has the right to request that Community Care provide an accounting ofdisclosures of PHI made by Community Care in the 6 years (or shorter time period) priorto the date in which the accounting is requested (as per the HIPAA Section 164.528).Community Care is not required to track disclosures prior to the implementationof the HIPAA Privacy Regulations.The member has the right to request an accounting of disclosures of his/herinformation by writing a letter to the privacy officer at Community Care.The privacy officer or his/her designee will review the member request and willrespond in 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 provided;that 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 each request.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 196
If granted, Community Care will release to the member an accounting of his/herdisclosed PHI.The privacy officer or his/her designee will oversee the process to account fordisclosures of PHI.This granted request for an accounting of PHI will be recorded in the MemberRequest to an Accounting of Protected Health Information Log, which will bemaintained by the privacy officer or his/her designee.The privacy officer or his/her designee will notify the manager of the file room tohave the member’s chart pulled. The following will be included in the accounting ofdisclosures:• The date of the disclosure.• A brief description of the information that was released.• A statement of the purpose of the disclosure or a copy of the signedauthorization.• The name of a person or provider who requested this information (CommunityCare reserves the right to deny the request for an accounting of disclosure ofinformation if divulging the name of the person who received information could bedetrimental to the member or the person to whom the information was disclosed).• A brief statement of Community Care policy on Disclosure of Information.• If there was more than one authorized release of information during therequested time period then, the frequency, periodicity, or number of thedisclosures made is included.• If the information was for, or in anticipation of, a civil, criminal, or administrativeaction or proceeding, Community Care will not release the information.• A flag will be placed in PsychConsult to notify employees that the member askedfor an accounting of disclosures.Once this information has been compiled, the information will be mailed in anenvelope marked “Confidential” to the address that the member specifies.Each year the first request for the accounting of information is free. After this,Community Care may charge a reasonable fee for preparing the information, as long asmembers are notified.If the privacy officer determines that the request should not be honored, within 30 dayshe/she will send the member a letter including the decision; the reason for the denial; adescription of the appeals process; the process for filing an appeal; and the name/titleand phone number of the contact person for the next step.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 197
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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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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
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
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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 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 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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