Billing Manual for Community Care Network Providers

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the member or provider for more information to assist in the disposition of thecomplaint. Upon receipt of a request for a Second Level Complaint review, Community Carewill provide the member with written notification regarding the Second LevelComplaint Committee Review procedures and hearing. The member will be notifiedof established protocols for the hearing process, investigation of the complaint, andthe role of the Second Level Complaint Review Committee. These protocols areconsistent with the requirements of the Department of Public Welfare and theDepartment of Health. A hearing of the Second Level Complaint Review Committee will be held within 30days of the receipt of the request for the hearing and will be conducted at a time andplace convenient to the member. The member will be notified in writing of thescheduled hearing at least 15 days in advance and will be invited to appear. Themember may elect not to attend the Second Level Complaint Review Committeehearing at his/her discretion; the hearing will be conducted by the same protocols asif the member were present. The member always has the right to attend and to present the case and has a rightto be assisted/represented by persons of his/her choice. The member may submitwritten material and has a right to question Community Care staff or the providerabout the complaint. The committee may not discuss the case to be reviewed prior to the second levelreview meeting. The committee shall base its decision solely upon the materials andtestimony presented at the review. Formal rules of evidence are inappropriate as this proceeding is envisioned as aninformal attempt to amicably resolve differences. The Second Level Complaint Review Committee is expected to conduct an informaland impartial proceeding using as the basis for their deliberation the written decisionof the First Level Complaint review. Committee members will be clearly identified asto staff and subscriber members. The Committee is to consider this dispute basedsolely on the material and presentations during the hearing. If an attorneyrepresenting the Second Level Complaint Review Committee is present, the attorneywill represent the interest of the impartial committee and not the staff memberinvolved in the dispute. Staff previously involved in the complaint may present andsummarize the decision for the Committee. The Committee will be permitted toquestion Community Care staff and the provider. An audio recording of the Second Level Complaint Review Committee hearing willbe made as required by the Department of Public Welfare and Department ofHealth. Electronic records will be kept for at least three years by the Complaint andGrievance Department. Access to this information will be limited to the director ofcomplaints and grievances, complaint and grievance coordinators, quality managers,Chief Clinical Officer, and Chief Medical Officer, or their designee, and will beavailable for appeal review by the Department of Health or Insurance Department. The Second Level Complaint Review Committee will issue a written decision withinfive business days of the hearing. The notice will contain: (a) an understanding ofthe complaint and pertinent facts; (b) the decision itself, the basis of the decision,and rationale; (c) an explanation of the member’s right to request review by theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 42
Department of Health and provide instructions for the member to request such areview. Community Care will assist the member in preparing the necessarydocumentation for the external review if requested to do so by the member.General Complaint Procedure ProvisionsA description of Community Care’s complaint procedure is communicated to membersthrough the Member Handbook, member newsletter (annual notification), routinecontact with Community Care representatives by telephone or mail, and is posted inprovider offices within members’ view.Community Care will comply with all requirements of the Department of Health andDepartment of Public Welfare to provide monthly, quarterly and annual reports on allcomplaints received. All such reports will contain member codes rather than identifyinginformation to ensure that member confidentiality is maintained of the complaintsystems/operational standards for fundamental fairness. The county or oversight entityhas access to all documentation regarding complaints and actions taken in response tocomplaints. If the county or its governance and oversight entity is in disagreement withany decision made by the Second Level Complaint Review Committee, the party withthe disagreement will prepare a summary document addressing his or herdisagreement. Copies of this document will for forwarded to Community Care and to theDepartment of Health.Community Care will accept complaints from individuals with disabilities which are inalternative formats including:TTY for telephone inquiries and complaints from members who are hearingimpaired.Braille, tape, computer disk, and other commonly accepted alternative forms ofcommunication.Community Care will provide members with disabilities assistance in presenting theircase at complaint reviews at no cost to the member. This includes:Providing qualified sign language interpreters for members who are severely hearingimpaired.Providing information submitted on behalf of Community Care at the complaintreview in an alternative format accessible to the member filing the complaint. Thealternative format version will be supplied to the member at or before the review, sothe member can discuss and/or refute the content during the review.Providing personal assistance to members with other physical limitations in copyingand presenting documents and other evidence.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 43
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 and 40: II.D.3 Providers’ Role in the Pre
Page 41: Community Care has a total of 30 ca
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
Page 90 and 91: If you, as a Community Care provide
Page 92 and 93:
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
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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