Billing Manual for Community Care Network Providers

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I.E.3 Pre-certification TeamCommunity Care maintains a dedicated team of care managers to conductprecertification reviews for acute levels of care. These care managers ensure thatindividuals’ needs and strengths have been assessed, that the specific level of carerequested meets MNC and that the requested level of care provides the least restrictiveenvironment for the member to continue the recovery process. In addition, the caremanagers on the precertification team may assist the member and provider inidentifying options and facilitating diversion planning. These care managers will alsofacilitate coordination of care efforts based on the member’s treatment history, currentauthorized services and active crisis plan.I.E.4 High Risk InterventionThis specific team of care managers works with members and their providers to resolvecomplex or high risk factors which impact the member’s ability to progress towardsrecovery. Face to face or telephone contact is focused on both the member andprovider. Because medical conditions often co-exist with a behavioral health diagnosis,coordinating care with physical health practitioners is also a priority.This team’s activities are driven by the needs and strengths of the individual memberwith frequent consultation with the Community Care professional advisors.Care managers focus on performance standards. They ensure that quality standards(performance standards) are met. Community Care created these standards inconjunction with providers, members, and other stakeholders with the goal of providingconsistent, high-quality care to all members. We accomplish this goal by offering writtenand specific quality standards by level of service and by using effective qualitymonitoring.To date, Community Care has created performance standards for:Acute Partial HospitalizationBehavioral Specialist ConsultationBHRS for Autism Spectrum DisordersCommunity Treatment Teams (CTT)Diversion and Acute Stabilization/RespiteDrug and Alcohol – Medically Monitored Short-Term Rehabilitation ProgramsDrug and Alcohol Partial HospitalizationFamily-Based Mental Health ServicesFamily-Focused Solution BasedIndividualized Residential Treatment/CRRInpatient ServicesMobile TherapyOutpatient ServicesPsychiatric RehabilitationCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 26
Psychiatric Rehabilitation ClubhousePsychologists and Psychiatrists Completing Best Practice EvaluationsResidential Treatment Facilities (RTF)School-Based OutpatientSchool-Based Partial Hospitalization ProgramSummer Therapeutic Activities ProgramTargeted Case Management: Intensive Case Management (ICM), ResourceCoordination (RC)TelepsychiatryCare Managers may refer to the “performance standards” as they are collaborating witha provider. Care managers ensure that:Clinical information given to the care manager meets the standards and guidelinesfor MNC review.All information is complete and up to date.Information is clear and specific.Performance standards for that specific level of care are met.Because care managers collaborate closely with providers during the utilizationmanagement process, they can often provide additional oversight, consulting, andmonitoring to those providers who may be having difficulty meeting networkbenchmarking standards.For information about approval standards refer to Guidelines for Obtaining Approval forIn-plan Services at the beginning of this guide. Authorization is based on administrativeand Medical Necessity Criteria. For information about Medical Necessity Criteria, referto Section IV.B or visit our website at:http://www.ccbh.com/providers/phealthchoices/medicalnecessityFor more information about Performance Standards, visit our website at:http://www.ccbh.com/providers/phealthchoices/performancestandardsCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 27
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: In order to serve special populatio
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
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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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