Billing Manual for Community Care Network Providers

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An open discussion of appropriate or medically necessary treatment options for theirconditions, regardless of cost or benefit coverage.Choose any provider from the Community Care provider list. Members are free tochange providers if they are unhappy.Have their information kept private and confidential.Know the name and qualifications of any provider caring for them.Voice complaints or grievances about Community Care or the care they receive andto see how Community Care responds to member complaints and grievances.Members have the right to a fair process that is easy to follow.Make recommendations about Community Care’s member rights andresponsibilities.Receive a copy of the information that Community Care uses when deciding whatcare the member should receive.Know about the services they are receiving, why they are receiving them, and whatto expect.Know everything they need to know to make decisions about their care.Work with providers or interpreters who understand them and their community.Get information about Community Care that is clear and easy to understand.Tell Community Care is they are unhappy about any decision made by CommunityCare or one of our providers. Members have the right to a fair process that is easy tofollow.Know about the qualifications of Community Care providers and staff.Receive information about options for their treatment. They have the right to receivethis information in a way that is easy to understand.Play a part in the decisions about their care. They also have the right to refusetreatment.Not be restrained (tied down or locked in) or left alone – as a way for someonegiving them treatment to bully or punish them, or as a way for that person to take abreak.Ask for a copy of their medical record. They have the right to correct informationinside their record.Know their rights and to not be treated differently because they do.A second opinion.Ask and learn more about “Advance Directives.”II.A.2 Member ResponsibilitiesIt is important for members to:Give Community Care and their provider the information needed to provide care forthem.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 30
Tell their provider everything they know about their physical and mental health. Also,they need to tell their provider what medicines they are taking, including over-thecounter(store bought) medicine(s).Tell their family doctor or primary care physician (PCP) about any counselingtreatment.Carry their ACCESS, physical health plan (or ACCESS Plus), and Community CareID cards with them.Go to a Community Care participating hospital in an emergency, if possible.Members need to call Community Care within 24 hours if they have been seen foran emergency at a hospital that is not in the Community Care provider network.Keep their appointments. Members need to call ahead to cancel if they must.Understand their health problems and work together with their provider and agreeupontheir treatment plan.Follow the treatment plan they agreed upon with their provider.Tell their provider if they want to stop or change treatment.Tell Community Care and their provider about any other insurance they have.Tell Community Care and their provider right away if their Medicaid status changes.Tell Community Care and their provider right away if they move.II.B. Member Help in Selecting ProvidersCommunity Care customer services representatives assist members who ask for help inidentifying a provider who will meet their needs. To obtain a selection of providers in therequested specialty, location, etc., the representative consults Community Care'sPsychConsult MCO ® database, which contains the most current information providershave supplied to Community Care. A representative may disclose the followinginformation about prospective providers to help the member choose:SpecialtyOffice location, telephone number, and office hoursGenderProfessional credentialsLanguages spoken by provider/provider staff if this information was disclosed on thecredentialing/recredentialing or assessment/reassessment application formA representative may not disclose providers' malpractice limits and/or history, NationalPractitioner Data Base information, or Drug Enforcement Agency (DEA) number. Arepresentative will not refer members to a provider who is not currently accepting newclients or indicate a preference of one provider over another. If the member requiresadditional assistance in selecting a provider, the call will be referred to a care manager.Members may ask to change their provider at any time.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 31
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 and 28: Psychiatric Rehabilitation Clubhous
Page 29: always be considered in light of th
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
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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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