Billing Manual for Community Care Network Providers

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First Level Complaint ProceduresMembers, or their designated representatives, may use any verbal or written means tolodge a complaint. They can call using one of Community Care’s toll-free numbers orsend their complaint in writing to their local Community Care office or to the corporateoffice:Community Care Behavioral Health Organization112 Washington PlaceOne Chatham Center, Suite 700Pittsburgh, PA 15219The Customer Service toll-free numbers, staffed 24 hours a day/seven days a weekwith staff trained to handle complaints, are listed on the HealthChoices Key ContactPage of this manual. The toll-free corporate clinical fax number is 1-888-251-0087.Community Care will offer impartial assistance at no cost to members who choose toexercise this right.Members may also seek assistance at any time during this process from multiplesources to include a community support person/advocate/family member.Personnel receiving and processing complaints will abide strictly by the CommunityCare Confidentiality policy. No Community Care provider or staff member may in anyway retaliate against a member who registers a complaint. If the complaint involvesa Community Care staff member, that individual may not participate in decisionsregarding resolution of the complaint.Immediately upon knowledge of a complaint, a Community Care staff member willdocument and log the complaint in PsychConsult MCO ® to include the followinginformation: (a) member’s name and ID number; (b) name of complainant (if otherthan member); (c) nature of the complaint and summary of the facts; (d) date andtime complaint received; (e) name of the staff member receiving the complaint; and(f) what the complainant requests as a resolution.A staff member will attempt to immediately resolve the problem by telephone within24 hours or one business day.Community Care will attempt to resolve complaints at the lowest level possible,ideally through the customer service representative.If resolution cannot be reached within 24 hours, the staff member will log thecomplaint in PsychConsult MCO ® and a complaint and grievance coordinator willcontact the provider or other party to investigate the complaint. The member ormember representative will receive written acknowledgement that a complaint hasbeen filed within five business days of Community Care’s receipt of the complaint.If the complaint is against a provider, Community Care will send that provider a copyof the complaint acknowledgment letter, outlining the member’s concern(s).The provider should then respond in writing to Community Care, addressing eachconcern in a simple and straightforward manner.Community Care will then review all information received, make a decision about thecomplaint, and propose a resolution to the member or their representative.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 40
Community Care has a total of 30 calendar days, from the date of receipt, topropose a resolution to the complaint.The staff member will notify the complainant of resolution in writing within fivebusiness days of the resolution. The letter informing the member of the resolutionwill include: (a) the understanding of the complaint; (b) steps taken to resolve thecomplaint; (c) basis for decision; (d) the decision itself; (e) procedures for filing aSecond Level Complaint, including assistance available in filing a complaint at thenext level.The Complaints and Grievances Department will maintain a database of allcomplaints and resolutions.Second Level Complaint ProceduresIf a member is not satisfied with the proposed resolution of a complaint, the memberhas 45 calendar days, from the receipt of the letter proposing the resolution, to utilizethe Second Level Complaint procedure.Community Care will offer impartial assistance at no cost to members who choose toexercise this right.The member or member representative may notify Community Care in writing or callcustomer services utilizing the toll-free hotline to verbally request assistance in filinga Second Level Complaint. Customer services will log the complaint in PsychConsultMCO ® and a complaint and grievance coordinator will coordinate and schedule thesecond level meeting.All requests for a Second Level Complaint will be logged, identifying: (a) themember; (b) complaint date; (c) nature of the complaint; and (d) the requestedSecond Level Complaint resolution.The complaint and grievance coordinator will acknowledge in writing to the memberor member representative that a request for Second Level Complaint has beenreceived within five business days of receipt of the complaint.If the complaint is against a provider, Community Care will send that provider a copyof the complaint acknowledgment letter, outlining the member’s concern(s).The Second Level Complaint will be reviewed by a Second Level Complaint ReviewCommittee appointed by Community Care, or in some instances, a Community Careoversight entity. This committee will consist of the following membership: one-thirdwill be members enrolled in Community Care and will include an adult/adolescentmember, a person in recovery, or the parent/guardian of children and adolescentmembers, depending upon the nature of the complaint, one-third will be committeemembers and employees of Community Care (or in some instances, a CommunityCare oversight entity employee) who were not directly involved in the issue that isbeing resolved at the second level, and one-third will be members not employed byCommunity Care. A representative of the county or oversight entity may participatein the Second Level Complaint review. The appropriate Community Carerepresentative(s) will gather information concerning the complaint and may contactCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 41
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 and 38: II.D.2b GoalsThe goals of Community
Page 39: II.D.3 Providers’ Role in the Pre
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
Page 88 and 89: 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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