Billing Manual for Community Care Network Providers

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I.D.1 Procedures for Suspected Fraud or AbuseAny Community Care staff member suspecting fraud must report the suspicion, either tohis or her supervisor or directly to Community Care's Fraud and Abuse Department. Thereport can be made via the Fraud and Abuse Hotline at 1-866-445-5190, e-mailed toCCBH_Fraud_Abuse@upmc.edu, or by submitting an internal referral to the Director orManager of the FWA Department. If the supervisor is notified first, he or she must reportthe suspicion to the Director of Fraud and Abuse within one business day of receivingthe staff member's report.Consequences of confirmed fraud include repayment of monies paid for the fraudulentclaims and the requirement to submit a corrective action plan that outlines how the auditexceptions will be prevented in the future. Notification of the identified fraud incident willbe sent to the Department of Public Welfare, Bureau of Program Integrity (DPW/BPI),the appropriate county administrators, and the county oversight entities. Suspension orexclusion from the Community Care network of providers may also occur as a result ofthe fraudulent activity.I.D.2 Avoiding Fraud and AbuseCommunity Care encourages providers to read this Provider Manual and/or call theProvider Line (1-888-251-2224) with any questions about standards of care,documentation and record keeping, claims/billing procedures, or any other activity thatcould be associated with a fraud or abuse concern. In addition, Community Care offersprovider training on these and other topics.I.D.3 Reporting Suspected Fraud and Abuse to the Department of Public WelfareThe Department of Public Welfare has established a hotline to report suspected fraudand abuse committed by any entity providing services to Medical Assistance recipients.The hotline number is 1-866-DPW-TIPS (1-866-379-8477) and operates between thehours of 8:30 a.m. and 3:30 p.m., Monday through Friday. Voice mail is available at allother times. Callers may remain anonymous and may call after hours and leave a voicemail if they prefer.Suspected fraud and abuse may also be reported via the DPW website at:http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/maprovidercompliancehotline1866dpwtips/index.htmInformation reported via the website can also be done anonymously. The websitecontains additional information on reporting fraud and abuse.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 22
I.E. Care Management Team“Advocates” is a word often used by others to describe Community Care’s caremanagement team because of their attention to quality, clinical effectiveness, memberchoice, and the recovery philosophy. This clinically focused team was created early inCommunity Care’s history—as the means to effectively assist members in makinginformed decisions about the services and supports that are available to them and toassist providers in quality service delivery through consultation and collaboration. Caremanagement focuses on:Adult mental health services.Services for children and adolescents.Drug and alcohol services.Dual diagnoses services.Service Precertification.Members identified as high risk.Care management uses diverse resources and team member expertise to ensure thatassistance is available to members and providers whenever needed.Care management operates 24 hours a day/seven days a week, with clinicalsupervisors on call at all hours. All care management staff have direct access toCommunity Care’s Professional Advisor staff, 24 hours a day. Care management worksclosely with other departments in Community Care, such as network management,information systems, quality management, and credentialing. In addition, CommunityCare’s prevention, outreach, communications, and training teams support members andproviders in other ways.The purpose of the care management team is to:Ensure that services are medically necessary and are being delivered at theappropriate intensity for a prescribed length of time with member participation as apart of the treatment team.Ensure coordinated care for all services and supports that the member is receivingand follow up care as a member is transitioning from one level of care to another.Monitor the quality of care in several ways, including review of treatment documents,attendance at team meetings, member and provider feedback, and analysis ofutilization information.Provide a responsive complaint and grievance process that ensures members canvoice their opinions about the care, services, and information they receive.Be available to answer questions from members and providers.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 23
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: Within 30 minutes for urban areas.W
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
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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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