Billing Manual for Community Care Network Providers

until the prescription runs out whichever is the shorter time period. If the memberrequests a DPW Fair Hearing before the effective date of the Second LevelGrievance decision, services must continue until the outcome of the DPW FairHearing is conveyed to the member or until the prescription runs out, whichever isthe shorter time period.Community Care may, at its discretion, assume that a member who files a First LevelGrievance which results in a continued denial will automatically file a Second LevelGrievance and automatically continue the service until the end of that time period.Community Care, at its discretion, can further assume that a member who receives adenial the Second Level Grievance will automatically request an External Grievanceand automatically continue services during that process.Standard GrievanceThe member or their designated representative may initiate a standard grievance inwriting or by phone, in which case, Community Care will acknowledge the receipt of thegrievance in writing. The member’s provider, with the member’s written permission, mayfile a grievance. This may be done via phone, or may be faxed or mailed to CommunityCare. If the grievance is filed via phone, the member or provider must follow up with awritten, signed grievance request.In order for the provider to represent the member in the filing of a grievance, theprovider must obtain the written consent of the member or the member’s guardian. Aprovider may obtain the member’s written permission at the time of treatment. Aprovider may NOT require a member to sign a document authorizing the provider to filea grievance as a condition of treatment.The written consent must include all of the following:The name and address of the member, the member’s date of birth and identificationnumber. If the member is a minor, or is legally incompetent, the name, address, andrelationship to the member of the person who signed the consent.The name, address and plan identification number of the provider to whom themember is providing consent.The name and address of the plan to which the grievance will be submitted(Community Care).An explanation of the specific service for which coverage was provided or denied tothe enrollee to which the consent will apply.The following statement: “The member or the member’s representative may notsubmit a grievance concerning the services listed in this consent form unless themember or the member’s representative rescinds consent in writing. The member ormember’s representative has the right to rescind consent at any time during thegrievance process.”Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 46