Billing Manual for Community Care Network Providers

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CONSENT FOR RELEASE OF INFORMATIONMENTAL HEALTHI hereby authorize __________________________________________________ to(name of facility, agency, school or person)release information from the records of:_______________________________________/_____________/_________________(name of Member) (DOB) (Med. Rec. #)For the specific purpose of:METHOD OF RELEASE (must check one): Verbal Only Copies Only Both The information to be released is: (Please check all that apply)Psychiatric EvaluationMedical HistorySocial HistoryDischarge SummaryCourse of TreatmentNeurologicalsLaboratory ReportsOther:Psychological/Achievement TestsDevelopmental HistoryAcademic/School RecordsSummary of HospitalizationTreatment RecommendationsMedicationOther Records (specify):Please forward information to theattention of:Facility/agency/person:Address:Phone:I have been told that, in order to protect the limited confidentiality of records, my agreement toobtain or release information is necessary and that this permission is limited for the purposes andto the person listed above, and will be effective for 90 days after the date of my signature, unlessspecified below. I also understand that this consent is revocable, by contacting the CommunityCare Privacy Officer in writing, except to the extent that action has been taken in reliance thereon.We will not condition treatment, payment, enrollment in Community Care Behavioral HealthOrganization, or eligibility for benefits on the person providing authorization for the requested useor disclosure.This consent shall be in effect from ____________________ until _____________________Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 202
(Date of signature)__________________________________(Witness)______________________________________Signature of Patient (14 years of age or older)______________________________________Signature of Parent/Legal Guardian/AuthorizedRepresentativeI do do not want a copy of this release____________________________________________________________________________________Oral Consent(Not Applicable to HIV-Related Information)For persons physically unable to provide a signatureI witnessed that the person understood the nature of this release and freely gave his/her oralconsent.Date of Signature:Signature of Witness:Date of Signature:Signature of Witness:Prohibition of redisclosure: The information has been disclosed to you from recordswhose confidentiality is protected by Federal Law. Federal regulations prohibit you frommaking any further disclosure of this information except with the specific written consentof the person to whom it pertains or as otherwise permitted by such regulations. Ageneral release of medical or other information is not sufficient for this purpose.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 203
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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
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164.504(e)(ii)(A)).They will take a
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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
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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 198 and 199: APPENDIX A.4. Significant Member In
Page 200 and 201: Orientation and ongoing provider ed
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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