Billing Manual for Community Care Network Providers

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III.E. Clinical Practice GuidelinesCommunity Care utilizes clinical practice guidelines to help practitioners and membersmake decisions about appropriate health care for specific clinical circumstances. Theseevidence-based guidelines are reviewed annually, updated as appropriate, andapproved by Community Care’s Quality and Care Management Committee (QCMC) andBoard Quality Improvement Committee (BQIC). Annually, Community Care measuresperformance against each of the clinical practice guidelines via claims data or recordreviews. Providers are notified of the results of these measurements via providernewsletters or web-based communications. Currently, the following guidelines are beingutilized:American Psychiatric Association Practice Guideline for the Treatment of Patientswith Major Depressive Disorder (Third Edition), October 2010.National Institute on Drug Abuse (NIDA) Principles of Drug Addiction Treatment: AResearch-Based Guide (Second Edition), April 2009.In addition to these to Clinical Practice Guidelines, Community Care adopted the APAPractice Guideline for the Treatment of Patients with Schizophrenia (Second Edition –April 2004) as well as the APA’s Treating Schizophrenia – A Quick Reference Guide.To obtain a copy of the APA guidelines, contact the American Psychiatric Association,1400 K Street NW, Washington, DC 20005 or visit the website:http://psychiatryonline.org/guidelines.aspxTo obtain a copy of the NIDA guideline, contact the National Institute of Drug Abuse,National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD20892. The guideline may also be obtained via the NIDA website at:http://www.nida.nih.gov/PODAT/PODATIndex.html.For information about our practice guideline measurements, contact Community Care at1-888-251-2224.III.F. New TechnologiesCommunity Care provides for a systematic assessment of new technologies and newapplications of existing technologies for behavioral health care, including clinicalinterventions, procedures, devices, and certain types of pharmacological treatments.Community Care’s New Technology Subcommittee, chaired by the Chief MedicalOfficer, meets on a routine basis to consider new technologies proposed for inclusion inCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 80
a benefits package. In those instances in which Community Care does not make thefinal decision on the inclusion or exclusion of a technology in the benefits package,Community Care assesses the new technology and makes a recommendation to theappropriate decision-making body.III.G. Unusual Incidents/Significant Member Incident Reporting (Patient Safety)A Significant Member Incident (SMI) or sentinel event is an unexpected and undesirableoutcome that has an adverse impact on the outcome of care. The detail of each SMI ispromptly reviewed to determine needed follow-up and to coordinate communicationbetween Community Care, the provider, and county agencies, as appropriate, to avoidunnecessary duplication of reports.Community Care receives information about SMIs in various ways. Examples of waysinformation about SMIs are received include staff, practitioner, provider, member,governmental reports, and publications.SMIs include but are not limited to:Completed suicides.Severe suicide attempts/self inflicted injury.Apparent serious physical accidents/suspicious deaths.Adverse effects of medications requiring medical intervention.Member injury due to restraint/seclusion.Apparent homicide or serious physical assault by client.Life threatening injury or illness while on provider site requiring hospitalization.Sexual/physical abuse complaint by member against provider.Sexual abuse/physical assault complaint incurred by member at provider site.Failure to follow mandated Childline reporting requirements.Elopement.Any fire requiring emergency services of the fire department.Arrest of a member active in treatment.Providers must report these events within 24 hours of the incident occurring or within 24hours of the provider learning of the incident. Providers may report SMIs by calling theProvider Line (1-888-251-2224), calling their designated care manager at CommunityCare, or faxing the incident report to the Quality Management Department at 1-888-249-5646. The provider is to inform Community Care when they become aware of any lossof life during treatment or within 30 days of treatment. Providers are also expected tocomply with all applicable state and federal laws and professional and legalrequirements regarding reporting of SMIs. Providers should report all cases ofsuspected child or elder abuse that involve a Community Care member to theappropriate agency as defined by law, as well as to Community Care.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 81
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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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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 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
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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
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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
Page 128 and 129: . 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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