Billing Manual for Community Care Network Providers

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Community Care is a party to the hearing and must participate in the hearing.Community Care, which may be represented by an attorney, must be prepared toexplain and defend the issue on appeal. The failure of Community Care toparticipate in the hearing will not be reason to postpone the hearing.Community Care must provide members, at no cost, with records, reports, anddocuments, relevant to the subject of the Fair Hearing.The Bureau of Hearings and Appeals has three business days from the receipt ofthe member’s oral or written request for an expedited review to process finaladministrative action. The Bureau of Hearings and Appeals’ adjudication is bindingon Community Care.III. About Being a Community Care HealthChoices ProviderCommunity Care's goals in developing and supporting a network of HealthChoicesproviders are to:Have a comprehensive range of providers to deliver all behavioral health servicescovered under HealthChoices regardless of participation in Federal Health CarePrograms under Sections 1128 or 1128A of the Social Security Act.Offer an adequate number of practitioners and facilities appropriately dispersedthroughout Community Care’s service area to allow for easy and convenient accessby members.Offer a sufficient number of specialist and ancillary providers to permit ample choicefor referrals regardless of cost.Community Care’s goals are also to include providers who:Serve high-risk populations.Have demonstrated a commitment to public sector consumers.Are committed to implementing treatment services that are consistent with theprinciples of the Community Support Program (CSP), Bureau of Drug and AlcoholPrograms (BDAP), and the Child and Adolescent Service System Programs(CASSP).Have worked to involve consumers and families actively in the design andimplementation of treatment programs.Have understood the relevance of psychosocial assessments in the design andimplementation of treatment.Represent both general and specific treatment skills.Will broaden access to assessment and treatment services, provided in a respectfuland competent manner.All providers of behavioral health services that are identified to participate in any ofCommunity Care’s networks are required to participate in a network managementCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 56
screening process prior to being offered an application. Community Care then reviewsthis information with its county partners prior to make a network inclusion decision.Community Care prospectively identifies member needs based on knowledge of priorservices used, psychosocial factors, member and family suggestions and providerexperience. The geographic distribution and demographic characteristics of membersare analyzed as well as the provider’s ability to meet the assessed and expectedmember needs.In the event that a provider is denied network inclusion, the provider is notified in writingby the Network Relations Department of the decision. A clear rationale for the decisionand an explanation of the right to appeal is included.Community Care contracts with the following types of providers of behavioral healthservices:Practitioners in individual or group practice (physicians, psychiatrists,addictionologists), doctoral or masters-level licensed clinical psychologists, doctoralor masters-level clinical psychiatric nurse specialists, doctoral or masters-levellicensed social workers and other masters or doctoral-level licensed behavioralhealth clinicians).Facilities (facilities and organizations).Providers (denotes information that applies to both practitioners and facilities).The Community Care credentialing program is committed to:Careful selection, credentialing, and recredentialing of practitioners to ensure thatmembers receive quality care and services from qualified professionals.Thorough assessment of facilities to ensure that members receive quality care andservices in a full continuum of settings.Maintaining the confidentiality of provider related information in the provider files aswell as the Credentialing Committee:• All Credentialing Department staff and reviewers sign employee confidentialitystatements.• All Credentialing Committee members sign confidentiality statements.• Each Credentialing Committee meeting is opened with a statement regarding theconfidentiality of printed material and discussions related to providers.• Provider specific materials prepared for the Credentialing Committee areproprietary and remain at Community Care following the CredentialingCommittee meeting.• Provider files are maintained in locked file cabinets at Community Care.Make available to providers, upon written request, the ability to view any materials,except recommendations, National Practitioner Data Bank (NPDB) responses, andother peer-review protected documents, submitted in relation to their applications.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 57
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 54 and 55: Notices must be in alternate format
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
Page 102 and 103: Timely File requests are to be mail
Page 104 and 105: 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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