Billing Manual for Community Care Network Providers

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Authorization for the Release of Drug and AlcoholInformation to the BHMCOI, ________________________________, authorize _________________________________(Provider)to release the following information to:Care Manager: ______________________________________________________________Community Care Behavioral Health OrganizationOne Chatham Center, Suite 700112 Washington PlacePittsburgh, PA 15219For the purpose of determining the advisability of certain treatment to coordinate myclinical care. Such authorization shall be limited to the following information:1. My presence in treatment2. Prognosis and diagnosis3. Nature of the treatment program4. Description of the treatment program5. Relapse statusThis release of information covers the treatment dates beginning ____________________and ending ________________________________.I may revoke this consent in writing to the Community Care Privacy Officer at any timeexcept as to any information released in reliance thereon to the date of such revocation.This consent will automatically expire 120 days from the date signed.I have been offered and have accepted/rejected a copy of this form (*please circle one)__________________________________________________Signature of Member__________________________________________________Signature of Witness_______________________Date_______________________DateI hereby revoke this consent effective ________________________. I understand that thisrevocation has no effect on information released prior to the date of this revocation.__________________________________________________Signature of Member_______________________DateProhibition 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 204
Authorization for the Release of Specific InformationI, ________________________________, authorize _________________________________(Provider)to release the following information to:Care Manager: ______________________________________________________________Community Care OrganizationOne Chatham Center, Suite 700112 Washington PlacePittsburgh, PA 15219For the purpose of determining the advisability of certain treatment to coordinate myclinical care. Such authorization shall be limited to the following information:1. My presence in treatment2. Prognosis and diagnosis3. Nature of the treatment program4. Description of the treatment program5. Relapse statusThis release of information covers the treatment dates beginning ____________________and ending ________________________________.I may revoke this consent in writing to the Community Care Privacy Officer at any timeexcept as to any information released in reliance thereon to the date of such revocation.This consent will automatically expire 120 days from the date signed.HIV related information contained in the parts of my clinical record may be released through this consentunless otherwise indicated: (Check one)_____ Consent to release of HIV information_____ Do not release HIV informationSignature to permit release of HIV/AIDS information contained in my medical records:__________________________________________________________________________________________________________________________________________________________Date_________________________DateI have been offered and have accepted/rejected a copy of this form (*please circle one)__________________________________________________Signature of Member__________________________________________________Signature of Parent/Guardian (when patient is under 14)_______________________Date_______________________DateCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 205
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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
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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 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 202 and 203: CONSENT FOR RELEASE OF INFORMATIONM
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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