Billing Manual for Community Care Network Providers

More documents

Recommendations

Info

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
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 and 18:
esources and evaluated on their pro
Page 19 and 20:
Confidentiality policies including
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
Page 68 and 69:
contracting, performance evaluation
Page 70 and 71:
the implementation and application
Page 72 and 73:
III.C.4 Ability to Give Informed Au
Page 74 and 75:
When such disclosure to health care
Page 76 and 77:
Practitioners are informed of the r
Page 78 and 79:
Medication(s) that have been prescr
Page 80 and 81:
III.E. Clinical Practice Guidelines
Page 82 and 83:
Community Care has developed a plan
Page 84 and 85:
eing served and uses strategies to
Page 86 and 87:
dialogue and intervention may occur
Page 88 and 89:
For any questions about providing s
Page 90 and 91:
If you, as a Community Care provide
Page 92 and 93:
When the precertification is for se
Page 94 and 95:
ORA member expresses a readiness fo
Page 96 and 97:
IV.E.3 Transition of Care to anothe
Page 98 and 99:
Billing ManualCommunity Care Behavi
Page 100 and 101:
Even though an authorization may be
Page 102 and 103:
Timely File requests are to be mail
Page 104 and 105:
Provide an alternative to the use o
Page 106 and 107:
Required Claim FieldsIn the followi
Page 108 and 109:
24C EMG Not required24D Procedure C
Page 110 and 111:
17 Discharge Status Required forINP
Page 112 and 113:
67a-q Diag. Code Required68 Unlabel
Page 114 and 115:
• Explanation of Benefits (EOB) i
Page 116 and 117:
Many of the services covered by Com
Page 118 and 119:
Community Care Behavioral Health Or
Page 120 and 121:
Community Care Procedure Code: The
Page 122 and 123:
C/FST: Consumer/Family Satisfaction
Page 124 and 125:
Medicaid/Medical Assistance identif
Page 126 and 127:
APPENDICESAPPENDIX A.1. Fraud, Wast
Page 128 and 129:
. The provider will also receive a
Page 130 and 131:
APPENDIX A.2. ConfidentialityPOLICY
Page 132 and 133:
A Facility or group practice name,
Page 134 and 135:
Confidential data and information s
Page 136 and 137:
The medical director or his/her des
Page 138 and 139:
The privacy officer will review the
Page 140 and 141:
collection and use of member identi
Page 142 and 143:
Protection of information disclosed
Page 144 and 145:
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
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
Page 170 and 171: “Statement of Confidentiality”
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
show all

Billing Manual for Community Care Network Providers

Create successful ePaper yourself

Delete template?

Save as template?