Billing Manual for Community Care Network Providers

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Notices must be in alternate formats that allow access for all individuals. The right toa DPW Fair Hearing may be exercised at the same time that the member uses theCommunity Care grievance process or in lieu of Community Care’s grievanceprocess. A copy of the notice must also be sent to the provider who requested theservice being denied.At all phases of Community Care’s grievance process, the member has the right torequest a DPW Fair Hearing from the OMHSAS Division of Grievances and Appeals.A member can appeal the initial determination and/or the results of the First orSecond Level of Grievance decision by Community Care.A member may request a Fair Hearing within 30 days of the date on the initial writtennotice of decision and within 30 days from the date on a complaint or grievancenotice of decision at any level, of any of the following:• The denial, in whole or in part, of payment for a requested service if based onlack of medical necessity.• The denial of a requested service on the basis that the service is not a coveredbenefit.• The denial or issuance of a limited authorization of a requested service, includingthe type or level of service.• The reduction, suspension, or termination or a previously authorized service.• The denial of a requested service but approval of an alternative service.• The failure to provide services in a timely manner, as defined by DPW.• The failure of Community Care to decide a complaint or grievance within thetimeframes specified by DPW.• The retrospective denial of payment because the service(s) was provided by anout of network non-Pennsylvania Medical Assistance participating providerwithout authorization.The request for a fair hearing must include a copy of the written notice of decisionthat is the subject of the request. Requests should be sent to:Department of Public WelfareOffice of Mental Health and Substance Abuse ServicesDivision of Grievance and AppealsBeechmont Building #32P.O. Box 2675Harrisburg, PA 17105-2675A member who files a request for a Fair Hearing to dispute a decision to discontinue,reduce, or change a service that the member has been receiving must continue toreceive the disputed service at the previously authorized level pending resolution ofthe Fair Hearing, if the request for a Fair Hearing is hand delivered or post-markedwithin 10 days of the date of the written notice of decision (within 1 calendar forurgent care decisions).Upon the receipt of the request for a Fair Hearing, the Department’s Bureau ofHearings and Appeals or a designee will schedule a hearing. The member andCommunity Care will receive notification of the hearing date by letter at least 10 daysin advance, or a shorter time if requested by the member. The letter will outline theCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 54
type of hearing, the location of the hearing (if applicable), and the date and time ofthe hearing.Community Care is a party to the hearing and must be present. Community Care,which may be represented by an attorney, will be prepared to explain and defend theissue on appeal. The DPW’s decision is based solely on the evidence presented atthe hearing.Community Care will provide members, at no cost, with records, reports, anddocuments, relevant to the subject of the Fair Hearing.The Bureau of Hearings and Appeals has up to 90 days from the receipt of a requestfor a Fair Hearing to process final administrative action. If the Bureau of Hearingsand Appeals has not taken final administrative action within 90 days of the receipt ofthe request, Community Care shall follow the requirements at 55 Pa. Code 275.4regarding the provision of interim assistance upon the request for such by themember. When the member is responsible for delaying the hearing process the timelimit for final administrative action will be extended by the length of the delayattributed to the member (55 Pa. Code 275.4).The Bureau of Hearings and Appeals’ adjudication is binding on Community Careunless reversed by the Secretary of Public Welfare. Either party may requestreconsideration from the Secretary within 15 days from the date of the adjudication.Only the member may appeal to Commonwealth Court within 30 days from the dateof adjudication (or from the Secretary’s final order, if reconsideration was granted).The decisions of the Secretary and the Court are binding on Community Care.Expedited Fair Hearing ProcessA request for an Expedited Fair Hearing may be filed with DPW either in writing ororally.A member does not have to exhaust the complaint or grievance process prior tofiling a request for an Expedited Fair Hearing.An Expedited Fair Hearing will be conducted if a member or a member’srepresentative provides the DPW with written certification from the member’sprovider that the member’s life, health, or ability to attain, maintain, or regainmaximum function would be placed in jeopardy by following the regular Fair Hearingprocess. This certification is necessary even when the member’s request for theExpedited Fair Hearing is made orally. The certification must include the provider’ssignature.A member who files a request for an Expedited Fair Hearing to dispute a decision todiscontinue, reduce, or change a service that the member has been receiving mustcontinue to receive the disputed service at the previously authorized level pendingresolution of the Fair Hearing, if the request for an Expedited Fair Hearing is handdeliveredor post-marked within 10 days of the date from the written notice ofdecision (within 1 calendar for urgent care decisions).Upon the receipt of the request for an Expedited Fair Hearing, the DPW’s Bureau ofHearings and Appeals or a designee will schedule a hearing.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 55
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 and 42: Community Care has a total of 30 ca
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 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
Page 94 and 95: ORA member expresses a readiness fo
Page 96 and 97: IV.E.3 Transition of Care to anothe
Page 98 and 99: Billing ManualCommunity Care Behavi
Page 100 and 101:
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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Billing Manual for Community Care Network Providers

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