Billing Manual for Community Care Network Providers

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Medication(s) that have been prescribed, dosages of each medication and the datesof initial prescription and of any changes in medication regimen.Current version of DSM diagnosis on all five axes (I, II, III, IV, and V) is documented.Complete developmental history is documented for children and adolescents.The following are documented:• Symptoms• Mental status• Member strengths and limitations• Compliance with treatment plan• Compliance with medication regimen, if appropriate• If the member has drug and alcohol issues (past and/or present), the results ofthe provider's inquiry as to the welfare of children and significant others living inthe home• Progress towards treatment goals• Coordination of care information, as applicable• Date of next session• Discharge planCommunity Care expects providers to maintain an organized treatment record keepingsystem. The following elements are required components of an organized recordkeeping system.A unique treatment record for each member.Treatment record notes maintained in chronological or reverse chronological order.An organized system for maintaining documents for each member; for example, alldiagnostic reports maintained together in a section of the folder.An organized filing system that provides easy access to unique member files.Consent to release information and informed consent documentation as appropriate.Treatment record documentation occurs as soon as possible after the encounterwith special status situations, such as imminent harm, suicidal ideation, orelopement potential prominently noted.Community Care expects all practitioners and facilities to provide treatment to membersin a safe environment. All providers should assess a member for suicidal ideation andhomicidal ideation throughout a member’s treatment. If a member is being treated in anoutpatient setting and expresses suicidal or homicidal ideation, the provider should takethe appropriate actions to ensure that the member and others are safe, such asfacilitating an inpatient hospitalization admission.Upon admission for an inpatient psychiatric hospitalization, the initial evaluationcompleted by the facility psychiatrist should clearly document that the member wasassessed for both suicidal and homicidal ideation. Additionally, members should beassessed for suicidal and homicidal ideation on an ongoing basis to ensure themember’s safety, as well as the safety of others. Providers should also proceed with aDuty to Warn if indicated.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 78
When a member is discharged from an inpatient hospitalization stay, a crisis planshould be developed by the facility and reviewed with the member upon discharge. Thecrisis plan should also include the phone number of the appropriate county services formental health emergencies.All medical records and reports completed by the provider for Community Caremembers are to be available, as appropriate, to practitioners and staff other than thetreating practitioner; Community Care; the Centers for Medicare and Medicaid Services(CMS; formerly the Health Care Financing Administration (HCFA); National Committeefor Quality Assurance (NCQA); or Pennsylvania Department of Health, licensing body,or regulatory agency; or other agencies as required by applicable law and regulations,for at least seven years after the initial date the provider delivered health care servicesto the member under contractual agreement with Community Care, regardless oftermination of the contractual agreement.The review of treatment record keeping practices, using a Medical Record Review Formis one component of the provider’s credentialing site visit. Facilities not accredited bythe Joint Commission on Accreditation of Healthcare Organizations (JCAHO),Committee on Accreditation of Rehabilitation Facilities (CARF), or Council onAccreditation of Services for Children and Families (COA) must meet the recordkeeping standards established by Community Care. Record keeping must also meet alllicensing regulations. The provider is sent the Medical Record Review Form instrumentprior to the scheduled site visit.The provider may prepare for the medical record review by designating an actualtreatment record for review, preparing a blinded treatment record, or preparing a mocktreatment record for review. The purpose of the credentialing medical record review is toensure that the provider has resources in place to collect the information neededthrough all stages of evaluation and treatment. A score of 80% is required to pass themedical record review. Providers are notified in writing if the score is below passing.When the score is below passing, the provider must submit a written corrective actionplan. A follow-up medical record review will be scheduled within six months to monitorimplementation of the provider’s corrective action plan.In addition, quality staff assess completeness of treatment records by using one or moreof the following methods:Reviewing a sample of treatment records on-site at the practitioner’s office.Obtaining a sample of treatment records from practitioners via mail or fax toCommunity Care.Reviewing treatment records sent to Community Care for other reasons.Community Care’s performance goal for completeness of treatment recorddocumentation is 80%. Aggregate results of the assessment of treatment recorddocumentation are communicated periodically to providers.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 79
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APPENDIX A.2. Confidentiality 130AP
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Clinical Fax by County:Adams 1-866-
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Outpatient Therapy 1MD OutpatientMe
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Functional Familytherapy (FFT)Multi
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Non-Acute PartialHospitalizationNot
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I.A. Code of EthicsCommunity Care
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esources and evaluated on their pro
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Confidentiality policies including
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Within 30 minutes for urban areas.W
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I.E. Care Management Team“Advocat
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In order to serve special populatio
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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 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
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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 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
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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
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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
Page 108 and 109: 24C EMG Not required24D Procedure C
Page 110 and 111: 17 Discharge Status Required forINP
Page 112 and 113: 67a-q Diag. Code Required68 Unlabel
Page 114 and 115: • Explanation of Benefits (EOB) i
Page 116 and 117: Many of the services covered by Com
Page 118 and 119: Community Care Behavioral Health Or
Page 120 and 121: Community Care Procedure Code: The
Page 122 and 123: C/FST: Consumer/Family Satisfaction
Page 124 and 125: Medicaid/Medical Assistance identif
Page 126 and 127: 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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