Billing Manual for Community Care Network Providers

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The following sections provide information about providing quality care to CommunityCare’s members, including how to become a contracted provider, how to maintainstandards for confidentiality, record keeping, provision of quality care, and other issuesaffecting providers:Practitioner Credentialing, Contracting, RecredentialingFacility/Organization Assessment, Contracting, ReassessmentConfidentiality and Disclosure PolicyRecord Keeping StandardsClinical Practice GuidelinesNew TechnologiesSignificant Member Incident Reporting (Patient Safety)Provider Cultural CompetencyProvider BenchmarkingProvider SatisfactionProvider EducationProvider Advisory CommitteeProviders are encouraged to call the Provider Line at 1-888-251-2224 (available 24hours a day/seven days a week) for assistance.Practitioner RightsThe organization’s policies and procedures include the right of practitioners to:Review information submitted to support their credentialing application.Correct erroneous information.Receive the status of their credentialing or recredentialing application, upon request.Receive notification of these rights.III.A. Practitioner Credentialing, Contracting, RecredentialingFor a practitioner, credentialing is the first step in Community Care's qualitymanagement process to ensure that members receive high-quality, responsive, andculturally-competent care.Practitioners who wish to provide services to members must complete the credentialingprocess before they are eligible to contract to provide services to members. Thepractitioner credentialing process includes evaluations of the practitioner (such aslicensing) and the site where services are to be provided.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 58
III.A.1 Practitioner Credentialing ProcessA practitioner is credentialed on the date in which the Credentialing Committee reviewsand approves the candidate's completed application.The Credentialing Committee ensures that practitioners initially meet and continue tomeet Community Care’s criteria and standards for participation in the network. TheCredentialing Committee reviews practitioner credentials and information for initialcredentialing and thereafter at least every three years.The practitioner credentialing process involves the following major steps: Each credential (degrees, certifications, licenses) must be verified with primarysources (academic institution, certifying body, licensing board or agency, etc.). Each practitioner evaluating or treating children and adolescents under the age of 18must submit a Pennsylvania State Police Criminal Background Check (Act 34),Pennsylvania Child Abuse History Clearance (Act 33), and FBI Background Checkthat are no older than 1 year from the date of submission. Each practitioner serving older (age 60 and older) or care dependent adults mustsubmit a Pennsylvania State Police Criminal Background Check that is no older than1 year from the date of submission. The completed application (all credentials verified with primary sources) must bereviewed and approved within 180 days of the date the application was signed. Ifnot, the application must be refreshed with Community Care by returning a copy ofthe original application with a new attestation to the practitioner to review for anychanges or additions. This application must be returned to Community Care with anewly signed and dated attestation.Verifying credentials with primary sources is performed by the CredentialingDepartment. This includes a review of information on sanctions or limitations withMedicare, Medicaid or state licensing agencies (NPDB, Cumulative Sanctions Report,Federal State of Medical Boards (FSMB), etc.).All criteria must be met and verified to consider the application complete forcredentialing.III.A.2 Change in Practitioner InformationAny change to information submitted by a practitioner during the credentialing andcontracting process, or at any time thereafter, including information such as streetand/or suite address and telephone and/or facsimile numbers, must be communicatedto Community Care's Network Relations Department.To prevent problems such as interruptions of referrals, failure to receiveauthorizations for services, or denial of payment for services provided toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 59
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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 56 and 57: Community Care is a party to the he
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
Page 106 and 107: 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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