Billing Manual for Community Care Network Providers

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ased on authorization and treatment plan data automatically receive an introductoryletter describing the program and information on how to opt out of the program if theydesire.The educational modules described above are mailed to participating parents/guardians. Following the introductory letter, newsletters are mailed approximately everyfour weeks. Parents/guardians are provided a toll-free number (1-866-639-2943) to callif they choose not to participate in the program or wish to have the newsletters sent to adifferent address.II.D.2f EvaluationAssessing the effect of this program is important for improving and further developingmaterials and services offered through Community Care. Parents/guardiansparticipating in the program are mailed a brief survey (with a postage paid envelope)assessing their perceptions of the usefulness of this program. Follow-up phone calls aremade to those parents/guardians who choose to provide contact information.II.D.2g What Providers Can DoCommunity Care’s prevention program is designed to increase parental/guardianknowledge of how to more effectively work and cope with the problems their child faces.Helping parents/guardians develop effective skills can have a more positive clinicaloutcome for the child whom you have evaluated or to whom you may be providingservices. Your support of this program is important to us. While Community Care willcontact parents/guardians automatically through the identification processes discussedabove, you are encouraged to inform parents/guardians of children with ADHD aboutthe program and, with their consent, call us at 1-866-639-2943 with the name of anymember who meets the inclusion criteria.Participating parents/guardians with questions may seek information from you regardingissues in the educational materials. We believe that the educational materials will helpparents/guardians understand the basics and encourage you to help them furtherdevelop or practice the skills necessary for parenting a child with ADHD.The provider and member materials are included on Community Care’s website, at thelinks above. If you do not have access to the Internet please call (toll free) 1-866-639-2943 and we will send the information to you. Please take the time to read thesematerials and give us your feedback.It is our hope that you find these materials a valuable addition to the care that youprovide. Should you have any questions or concerns, we would be pleased to addressthem. To discuss the program, please call 1-866-639-2943.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 38
II.D.3 Providers’ Role in the Preventive Health ProgramProviders play an important role in the success of the Preventive Health Program.Community Care asks providers to make the educational newsletters available in theiroffices and to tell suitable members about the programs. In addition, Community Careasks providers to answer member questions about the educational newsletters and toprovide additional information if requested. Providers are also welcome to contactCommunity Care with suggestions or to learn about future programs.II.E. Member Complaint and Appeal ProceduresCommunity Care’s policy for the resolution of complaints has been developed toestablish an objective review process to investigate and resolve all complaints in anappropriate and timely manner and to meet all county, state, and NCQA requirements.We ensure impartial review by designating reviewers who are not associated with theissue being considered and have not already reviewed the issue.InquiryAn inquiry is defined as any member’s request for administrative services orinformation, or expressing an opinion. Whenever specific corrective action is requestedby the member or determined to be necessary by Community Care, an inquiry isclassified as a complaint.ComplaintA complaint is defined as a dispute or objection by a member or their representative,which may include the member’s provider, with proof of the member’s writtenauthorization for the representative, to be involved and/or take action on the member’sbehalf, regarding a participating health care provider, or the coverage (includingcontract exclusions and non-covered benefits), operations, or management policies ofCommunity Care that has not been resolved by our organization and has been filed withCommunity Care, the Pennsylvania Department of Health, or the PennsylvaniaInsurance Department. The term does not include a grievance.Second Level ComplaintA statement of disagreement, either written or oral, with the resolution of a complaint,which is perceived to be unsatisfactory by the member, which is subject to a secondlevel review within a 30-day timeframe.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 39
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 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: II.D.2b GoalsThe goals of Community
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
Page 82 and 83: Community Care has developed a plan
Page 84 and 85: eing served and uses strategies to
Page 86 and 87: 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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