Billing Manual for Community Care Network Providers

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APPENDIX A.4. Significant Member IncidentsPolicyA Significant Member Incident (SMI) or sentinel event is an unexpected and undesirableoutcome that has an adverse impact on the outcome of care. The detail of each SMI ispromptly reviewed to determine needed follow-up and to coordinate communicationbetween Community Care, the provider, and county agencies, as appropriate, to avoidunnecessary duplication of reports.Community Care receives information about SMIs in various ways. Examples of waysinformation about SMIs is received include staff, practitioner, provider, member,governmental reports, and publications.SMIs include but are not limited to:Completed suicides.Severe suicide attempts/self inflicted injury.Apparent serious physical accidents/suspicious deaths.Adverse effects of medications requiring medical intervention.Member injury due to restraint/seclusion.Apparent homicide or serious physical assault by client.Life threatening injury or illness while on provider site requiring hospitalization.Sexual/physical abuse complaint by member against provider.Sexual abuse/physical assault complaint incurred by member at provider site.Failure to follow mandated Childline reporting requirements.Elopement.Any fire requiring emergency services of the fire department.Arrest of a member active in treatment.All incidents must be reported to Community Care within 24 hours of the incidentoccurring or within 24 hours of learning of the incident.ProcedureCommunity Care has developed a plan for significant incidents that ensures promptreview of the detail related to each incident and determining needed follow-up. Thisprocess will coordinate communication between the provider, Community Care, thecounty, and the oversight agency. As a result, duplication of reports will be minimal andfurther contact with the provider specific.Providers should report SMIs to Community Care within 24 hours of the incidentoccurrence or of the provider learning of the incident. The provider will informCommunity Care when they become aware of any loss of life during treatment or within30 days of treatment.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 198
The individual receiving information about a SMI initiates the Significant MemberIncident Form and enters the information into a database. At a minimum, the dataelements include:Date information about when the SMI is received.Date SMI occurred.Member name and identification number.Provider name and contact number.Nature of the SMI.All SMIs are forwarded to the quality clinician, SMI coordinator within one business dayof the date the information became known to Community Care. The quality clinician,SMI coordinator:Reviews the issue thoroughly and determines the urgency of the SMI.Determines the appropriate individual to investigate the SMI.Notifies the Chief Medical Officer or designee about the SMI [each occurrence ofunexpected and undesirable outcome that has an adverse impact on the outcome ofcare must be thoroughly reviewed by the Chief Medical Officer or designee]. Seniormanagement determines when legal counsel should be informed about a SMI.Documents all information and actions on the Significant Member Incidents Form.Contacts the provider or others as needed.Obtains additional information, as needed to conduct a thorough investigation of theSMI, including any aspects of clinical care and safety involved.Obtains the medical records from the provider, if necessary.Conducts an office site visit if needed for issues such as office safety.Tracks the SMI to resolution.A written report of the findings of the review including any recommendations iscompleted for each SMI. A copy of the completed SMI investigation results will beforwarded to the county/oversight agency when indicated.Identifying and monitoring SMIs is part of the quality improvement activities, whichCommunity Care performs as part of our comprehensive provider evaluation process(CPEP). Community Care will direct any media inquiries regarding SMIs to the SeniorDirector of Quality Management and inform the members of senior management atCommunity Care of the incident.Providers are expected to report all cases of child abuse to the appropriate reportingagency as defined by law. They are also expected to report this to Community Carewhen it involves one of our members. We will track this through our SMI reportingmechanisms. The provider may report this either verbally or in writing. The Childlinephone number for reporting suspected cases of child abuse is 1-800-932-0313.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 199
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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
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Under some circumstances, it may be
Page 148 and 149: 164.504(e)(ii)(A)).They will take a
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Page 152 and 153: esults, billing records, and treatm
Page 154 and 155: equestor destroy the information, o
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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
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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
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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
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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 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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Billing Manual for Community Care Network Providers

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