Billing Manual for Community Care Network Providers

Determinations will be made within 30 calendar days of the request for a First LevelGrievance. The final determination will be in writing and sent to the member withinfive business days of the decision and will include the clinical reasons for thegrievance determination.Community Care may extend the timeframe for determination by up to 14 calendardays if the member requests the extension, or if Community Care shows that there isneed for additional information, and states how the extension is in the member’sbest interest.The basis for the determination will be provided to the attending practitioner and themember. The member will be informed of their right (and how) to file a Second LevelGrievance with Community Care, or a DPW Fair Hearing.First Level Grievance: Urgent ServiceIf the service prescribed is in response to an urgent situation, Community Care willnotify the member and provider by phone, follow up in writing, and apprise them ofthe full or partial denial of authorization for the service or the approval of analternative to the prescribed service and the member’s right to appeal that decision.If the member, either verbally or in writing, or the provider, with written permission ofthe member, indicates that the member wishes to grieve the decision, it will bereviewed by a professional advisor (PA). The reviewer cannot be the same PA whomade the original denial decision. This decision will be rendered within 24 hours ofreceipt of the grievance.If the First Level Grievance results in a determination that Community Care willauthorize provision of the service as originally prescribed, the member and theprovider must be notified by phone, followed-up in writing within 48 hours.If the First Level Grievance results in a determination that Community Carecontinues to deny authorization for provision of the service or continues to approvean alternative to the prescribed service, the member and provider will be notified byphone, followed-up in writing, also within 48 hours.The notice will inform the member of the member’s right to a Second LevelGrievance and provide information about how to request a Second Level Grievance.Community Care must assist the member, if necessary, to make a written request.The notice will also inform the member of the member’s right to request a DPW FairHearing and how to file for a Fair Hearing.First Level Grievance: Non-urgentIf the service prescribed is not in response to an urgent situation, Community Carewill notify the member and provider, in writing, of the full/partial denial ofauthorization for the service or the approval of an alternative to the prescribedservice, the effective date of the decisions, and the member’s right to grieve thatdecision. A copy of the written denial will be provided to the parent/guardian of achild or adolescent or to the county’s Children and Youth Services (subject to anyCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 48