Billing Manual for Community Care Network Providers

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__________________________________________________Signature of Witness_______________________Date____________________________________________________________________________ORAL CONSENT (only for persons physically unable to provide a signature)I witnessed that __________________________ (Member’s name) understood the natureof this Consent to Release, understood that s/he may orally revoke this consent at anytime except as to the information released in reliance thereon to the date of such oralrevocation and that s/he freely gave his/her oral consent. (Two witnesses required)__________________________________________________Witness__________________________________________________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 206
Sample Letter for Permission to Share Information forCollaboration between Physical Health and Behavioral Health Organizationsor Practitioners(Practice Letterhead)Primary Care Physician/Behavioral Health Clinician Name:Address:Fax #Date_______________________________________________________________________________________________________________Dear Provider:Your patient, ___________________________________, is being treated forsymptoms of ___________________________________.I/We have recommended the following treatment: ______________________________________________________________________________________________________________________________________________________________________________ Individual Therapy____ Group Therapy____ Pharmacotherapy____ Family/Couples Therapy____ Psychiatric Evaluation for Medication____ No treatment recommended at this timeThe following medication(s) have been prescribed:Medication: ______________________________Dose/frequency: ______________________________ No medication at this timePlease feel free to contact me at (xxx-555-5555) if you feel there are coordination ofcare issues that we should discuss.Sincerely,(Provider name, title, signature)Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 207
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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
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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 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 204 and 205: Authorization for the Release of Dr
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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