Billing Manual for Community Care Network Providers

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APPENDIX C.1. Priority PopulationsMENTAL HEALTH - ADULTIn order to be in the Adult Priority Group, a person: must meet the federal definition ofserious mental illness 1 ; must be age 18+, (or age 22+ if in Special Education); musthave a diagnosis of schizophrenia, major affective disorder, psychotic disorder NOS orborderline personality disorder (DSM-IV or its successor documents as designated bythe American Psychiatric Association, diagnostic codes 295.xx, 296.xx, 298.9x or301.83); and must meet at least one of the following criteria:A. Treatment HistoryB. Functioning Level orC. Coexisting Condition or CircumstanceA. TREATMENT HISTORYCurrent residence in or discharge from a state mental hospital within the past twoyears; orTwo admissions to community or correctional inpatient psychiatric units or residentialservices totaling 20 or more days within the past two years; orFive or more face-to-face contacts with walk-in or mobile crisis or emergencyservices within the past two years; orOne or more years of continuous attendance in a community mental health or prisonpsychiatric service (at least one unit of service per quarter) within the past two years;orHistory of sporadic course of treatment as evidenced by at least three missedappointments within the past six months, inability or unwillingness to maintainmedication regimen or involuntary commitment to outpatient services; orOne or more years of treatment for mental illness provided by a primary carephysician or other non-mental health agency clinician, e.g., Area Agency on Aging,within the past two years.B. FUNCTIONING LEVELGlobal Assessment of Functioning Scale (DSM-IV-TR, pages 12 and 20) rating of 50 orbelow.______________________1 Adults with serious mental illness are persons age 18 and over, who currently or at any time during thepast year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meetdiagnostic criteria specified within DSM-IV that has resulted in functional impairment which substantiallyinterferes with or limits one or more major life activities. (See Reference for additional detail)Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 208
C. COEXISTING CONDITION OR CIRCUMSTANCE1. Coexisting Diagnosis:a. Psychoactive Substance Use Disorder; orb. Mental Retardation; orc. HIV/AIDS; ord. Sensory, Developmental and/or Physical Disability; or2. Homelessness 2 ; or3. Release from Criminal Detention 3In addition to the above, any adult who met the standards for involuntary treatment (asdefined in Chapter 5100 Regulations - Mental Health Procedures) within 12 monthspreceding the assessment is automatically assigned to the high priority group.MENTAL HEALTH - CHILD AND ADOLESCENTThe Child and Adolescent First Priority Group includes persons who meet all fourcriteria below:1. Age: birth to less than 18 (or age 18 to less than 22 and enrolled in specialeducation services).2. Currently or at any time in the past year have had a DSM-IV diagnosis (excludingthose whose sole diagnosis is mental retardation or psychoactive substance usedisorder or a "V" code) that resulted in functional impairment which substantiallyinterferes with or limits the child's role or functioning in family, school, orcommunity activities.3. Receive services from mental health and one or more of the following:a. Mental Retardationb. Children and Youthc. Special Educationd. Drug and Alcohole. Juvenile Justicef. Health (the child has a chronic health condition requiring treatment).4. Identified as needing mental health services by a local interagency team, e.g.,CASSP Committee, Cordero Workgroup.In addition to the above, any child or adolescent who met the standards for involuntarytreatment within the 12 months preceding the assessment (as defined in Chapter 5100– Mental Health Procedures) is automatically assigned to this priority group._______________________2 Homeless persons are those who are sleeping in shelters or in places not meant for human habitation,such as cars, parks, sidewalks or abandoned buildings.3 Applicable categories of release from criminal detention are jail diversion; expiration of sentence orparole; probation or Accelerated Rehabilitation Decision (ARD).Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 209
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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
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The member has the right to request
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Page 172 and 173: Findings will be reported to senior
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Page 178 and 179: NameAddress (es)Zip CodeDiagnosis (
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Page 186 and 187: For research purposes.On behavioral
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Page 192 and 193: The request must be in writing. Cre
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Page 204 and 205: Authorization for the Release of Dr
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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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