Billing Manual for Community Care Network Providers

this email in error, please notify the sender by return email, securely delete this fileand any electronic or magnetic copies and destroy any paper copies.”Telefacsimile (fax) machines must be located where faxes may not be intercepted orviewed by individuals not authorized to access member identifiable information.When member identifiable information is transmitted by fax, a confidentiality noticesimilar to the following must be prominently displayed on the cover sheet: “Thisfacsimile transmission contains confidential and privileged information for use onlyby the intended recipient. Do not read, copy, or disseminate this material unless youare the intended recipient. If you believe you have received this message in error,please notify the sender by facsimile or telephone and destroy this document.”Please call the Provider Line (1-888-251-2224) for any authorization for release ofinformation forms that might be needed in the care of members.III.D. Record Keeping StandardsCommunity Care has established treatment record documentation guidelines,performance goals, and standards for availability of treatment records to facilitateaccurate record keeping, communication between practitioners and coordination andcontinuity of care within the behavioral health continuum and the medical deliverysystem. Community Care expects providers to implement these treatment recorddocumentation guidelines.Each member’s medical record must meet the following standards:The member address, employer or school, home and work telephone numbers,emergency contacts, marital/legal status, authorization forms, and guardianshipinformation is documented, as relevant.The member's name or identification number is present on each page.The responsible clinician's name and professional degree are documented.All entries are dated.The record is legible.Relevant medical conditions are listed, prominently identified, and updated.Presenting problems and relevant psychological and social conditions affecting themember's medical and psychiatric status are documented.Special status situations such as imminent risk of harm, suicidal ideation, orelopement potential are prominently noted, documented, and updated in compliancewith written protocols.Past medical and psychiatric history is documented, including previous treatmentdates, provider information, therapeutic interventions and responses, sources ofclinical data, relevant family information, results of laboratory tests, and consultationreports.Allergies and adverse reactions are clearly documented.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 77