Billing Manual for Community Care Network Providers

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I.C.2 MeasurementExplicit, well-defined critical performance measures are the essential component ofCommunity Care's quality management program. Critical performance indicatorsrepresent what is most important to Community Care in defining quality. They aredeveloped using sound methodological principles. The performance data that resultfrom measurement are reliable so that decisions can be made with confidence.Measurements are specifically defined in Community Care’s quality assurance WorkPlans. Each topic includes the measurements, goals, and timing of each activity. On anannual basis, Community Care publishes the results of Work Plan monitoring activitiesand studies in our communications. Interventions and results are also described.I.C.3 Record ReviewCertain measurements in Community Care’s annual Quality Management Work Planrely upon data collection through confidential record review. Selected network providersare contacted in advance of a record review. Areas of focus include topics such asaccessibility to covered services, appointment availability, coordination of care, qualityof care, and record keeping. Community Care expects providers to agree to furnishpertinent sections of an enrollee’s medical records, consistent with appropriate rules ofconfidentiality for patient records as described in the Network Provider Agreement andas specifically required by HealthChoices.I.C.4 Quality Management Program StructureThe quality management program description describes the structure and processes ofthe quality management program. The Work Plan lists the activities that comprise thequality management program. The Quality and Care Management Committee (QCMC)oversees implementation of the program and Work Plan.The quality management program is designed to continuously improve performance andprovide members with high-quality, cost-effective healthcare services, access andavailability to culturally competent healthcare providers and services, continuity andcoordination of care across all heath care delivery settings, and effective behavioralhealth prevention programs and health education services.I.C.5 Availability StandardsCommunity Care monitors availability by category of service, through its GeoAccessreporting capabilities, to ensure access to a Provider:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 20
Within 30 minutes for urban areas.Within 60 minutes for rural areas.These measures are included in the Quality Management Work Plan.I.C.6 Accessibility StandardsCommunity Care monitors access to routine, urgent, and emergent appointments:A routine request for an appointment met within seven days.An urgent request for an appointment met within 24 hours.A non-life-threatening request met within one hour.A life-threatening emergency met immediately.These measures are included in the Quality Management Work Plan. Refer to SectionIV.D. for more information about accessibility.I.D. Compliance with Fraud and Abuse ReportingTo fulfill our mission and to act in accordance with our values, code of conduct, andpolicies, Community Care monitors and investigates suspected fraud and abuse,defined as follows:Fraud is an intentional deception or misrepresentation made by a person with theknowledge that the deception could result in some unauthorized benefit to him orsome other person. Examples of fraud could include a provider submitting a bill for aservice that did not occur, billing for a time period greater than the time actuallyspent with the client, billing for provision of a service that did not meet the servicedefinitions, billing or charging Medical Assistance recipients for covered services,billing more than once for the same service, or dispensing generic drugs and billingfor brand name drugs.Abuse by a provider is defined as provider practices that are inconsistent with soundfiscal, business, or medical practices and result in unnecessary costs or inreimbursement for services that are not medically necessary or that fail to meetprofessionally recognized standards for health care. "Abuse" also includesCommunity Care member practices that result in unnecessary costs.Community Care monitors for possible fraud and abuse within our provider network byconducting audits, investigating fraud, waste, and abuse (FWA) referrals, and analyzingbilling and payment data. When suspected fraud or abuse is identified, Community Carereports these occurrences to appropriate licensing, reporting, and investigative agenciesand takes appropriate action to prevent future fraud or abuse.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 21
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: Confidentiality policies including
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
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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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Policy on Release of Information Re
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y the written authorization of the
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If minor consents to treatment or c
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Current patients or clients or the
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If the client has given written aut
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Confidentiality policies pursuant t
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“Statement of Confidentiality”
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Findings will be reported to senior
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information and by signing this sta
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Community Care has identified circu
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NameAddress (es)Zip CodeDiagnosis (
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Community Care has the right to den
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Member identifiable information may
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Community Care extends all reasonab
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For research purposes.On behavioral
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See the policy on Transition of Pri
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Community Care does not collect inf
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The request must be in writing. Cre
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All statements to the media includi
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• The name, or title, and the tel
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APPENDIX A.4. Significant Member In
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Orientation and ongoing provider ed
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CONSENT FOR RELEASE OF INFORMATIONM
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Authorization for the Release of Dr
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___________________________________
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APPENDIX C.1. Priority PopulationsM
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Second priority is associated with
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3. Secondary Data - OMHSAS will dev
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BEHAVIORAL HEALTH MANAGED CARE ORGA
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APPENDIX E.1. Companion Guide for N
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