Billing Manual for Community Care Network Providers

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II. About Community Care HealthChoices MembersCommunity Care’s HealthChoices members are individuals for whom Community Carehas been contracted to manage behavioral health—mental health or drug and alcohol—services (See Guidelines for Obtaining Approval for In-plan Services at the beginning ofthis Provider Manual).When Community Care receives enrollment information, our Customer ServicesDepartment verifies eligibility. Customer services representatives serve as the point ofcontact for members until they use a service other than routine outpatient behavioralhealth services, at which time a care manager is assigned.Community Care offers a toll-free Members’ Line that is staffed 24 hours a day, sevendays a week to address all member inquiries and concerns, including services covered,selecting a behavioral health provider, out-of-area care, and complaints. In accordancewith quality standards, the member is able to speak to a customer servicesrepresentative at any time of the day or night. Every members is encouraged to read theCommunity Care Member Handbook.Information concerning members and services that providers need to know is describedin the following Sections:A. Member Rights and ResponsibilitiesB. Member Help in Selecting ProvidersC. Member SatisfactionD. Member Behavioral Health Preventive Health ProgramsE. Member Complaint and Appeal ProceduresF. Member GrievancesProviders are asked to urge members who have questions about their behavioral healthcare to call the toll-free Community Care Members' Lines (Customer service phonenumbers are listed by county in the Contact Information section of this manual).II.A. Member Rights and ResponsibilitiesAll members of Community Care have certain rights and responsibilities. Every staffperson and provider has the obligation and responsibility to know these rights andresponsibilities and to support them in daily operations.Member responsibilities are intended to serve as guidelines to help the member,provider and others work cooperatively and effectively for the member's benefit.Member responsibilities are not a threshold (required) standard of behavior and mustCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 28
always be considered in light of the nature of the member's illness and his or herparticular circumstances.II.A.1 Member RightsConfidentiality:Community Care will not disclose information about a member’s care withoutpermission, except when:It is required for the monitoring activities of Community Care, the counties, and/orthe state.Required by law.Members have the right to ask for a copy of the following information:The names, addresses, and phone numbers of providers who speak otherlanguages.The names, addresses, and phone numbers of providers who are not accepting newpatients.Any reasons why they could not choose a provider of service. For example,Community Care will not provide referral information for treatment services that arenot generally recognized by doctors.Their member rights and responsibilities.Information about grievances and fair hearing procedures.The benefits available to them, in detail.How to learn about additional benefits from the state of Pennsylvania.The steps that they (or a provider) need to take to receive services.The steps that must be taken to use a provider of service who is not in the network.Information about the emergency benefits available to them including “what is anemergency”; the steps for getting emergency services (including calling 911); thenames, addresses, and phone numbers of providers of emergency services,emergency services not requiring approval; any hospital being used when there isan emergency; and how emergency transportation is provided.Members also have the right to:Receive information about Community Care, our services, our providers, and themember rights and responsibilities.Receive proper treatment regardless of race, color, religion, lifestyle, sexualorientation, disabilities, national origin, age, gender, or income.Be treated in a considerate and respectful manner with recognition of their dignity.Receive services where their privacy is protected.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 29
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 and 26: In order to serve special populatio
Page 27: Psychiatric Rehabilitation Clubhous
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
Page 76 and 77: Practitioners are informed of the r
Page 78 and 79:
Medication(s) that have been prescr
Page 80 and 81:
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
Page 102 and 103:
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
Page 130 and 131:
APPENDIX A.2. ConfidentialityPOLICY
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A Facility or group practice name,
Page 134 and 135:
Confidential data and information s
Page 136 and 137:
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
Page 214 and 215:
BEHAVIORAL HEALTH MANAGED CARE ORGA
Page 216 and 217:
APPENDIX E.1. Companion Guide for N
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Billing Manual for Community Care Network Providers

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