Billing Manual for Community Care Network Providers

II.F. Member GrievancesCommunity Care is accountable to its members for the effective utilization of resourcesin the provision of health care and the quality of care and services provided by ourparticipating providers. Community Care reviews requests from providers for behavioralhealth services to ensure that only medically necessary services are approved. TheCommunity Care review may result in the denial of a requested service for a lack ofdocumented medical necessity or a recommendation for alternative services to achievethe proposed treatment outcomes.From time to time, a member, a family member or parent/guardian of a member will notbe in agreement with determinations of medical necessity made in fulfillment of thisaccountability. At such times, the member, their provider (with written permission of themember), or the parent/guardian (if the member is a minor or in foster care), have theright to file a grievance in writing to Community Care. Grievances are available toaddress disagreements in adverse determination decisions. All Community Carepersonnel involved in this grievance procedure shall comply with all policies regardingconfidentiality and conflict of interest to ensure that the confidentiality of memberinformation is maintained.If services which have previously been authorized by Community Care are beingdiscontinued or reduced by our organization, we acknowledge an obligation to continueauthorization of care until all formal grievances have been completed, consistent withthe requirement of the Department of Public Welfare (if grievances are requested withinrequired timeframes).GrievanceA grievance is a request by a member or their authorized representative, or by a healthcare provider with the written consent of the member or guardian, to have CommunityCare or a Certified Review Entity (CRE) reconsider a decision solely concerning themedical necessity and appropriateness of a health care service. If Community Care isunable to resolve the matter, a grievance may be filed regarding the decision that doesany of the following:Disapproves full or partial payment for a requested health service.Approves the provision of a requested health care service for a lesser scope orduration than requested.Disapproves payment of the provision of a requested health care service butapproves payment for the provision of an alternative health care service. The termdoes not include a complaint.Information regarding Community Care’s policies and procedures regarding grievancesis made available to the provider network through their inclusion in the Provider Manual.Provider training includes a review of these policies.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 44