Billing Manual for Community Care Network Providers

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Community Care has developed a plan for identifying SMIs that ensures prompt reviewof the detail related to each incident and determining needed follow-up. This processcoordinates communication between the provider, Community Care, the county, and theoversight agency. As a result, duplication of reports is minimal and further contact withthe provider specific.The individual receiving information about a SMI initiates the Significant MemberIncident Form and enters the information into a database. The data elements include ata minimum the:Date information about when the SMI is received.Date SMI occurred.Member name and identification number.Provider name and contact number.Nature of the incident.All SMIs are forwarded to the quality clinician, SMI coordinator within one business dayof the date the information became known to Community Care. The quality clinician,SMI coordinator:Reviews the issue thoroughly and determines the urgency of the SMI.Determines the appropriate individual to investigate the SMI.Notifies the Chief Medical Officer (CMO) or designee about the SMI (eachoccurrence of unexpected and undesirable outcome that has an adverse impact onthe outcome of care must be thoroughly reviewed by the CMO or designee).Documents all information and actions on the Significant Member Incident Form.Contacts the provider or others as needed.Obtains additional information, as needed to conduct a thorough investigation of theSMI, including any aspects of clinical care and safety involved.Obtains the medical records from the provider, if necessary.Conducts an office site visit if needed for issues such as office safety.Tracks the SMI to resolution.Prepares a written report of the findings of each SMI review including anyrecommendations.Forwards a copy of the completed SMI investigation results to the county/oversightagency when indicated.Identifying and monitoring SMI is part of quality improvement activities, whichCommunity Care performs as part of our comprehensive provider evaluation process(CPEP). Community Care directs any media inquiries regarding SMIs to the SeniorDirector of Quality Management and informs all other members of senior managementat Community Care of the incident.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 82
Providers are expected to report all cases of child abuse to the appropriate reportingagency as defined by law. They are also expected to report this to Community Carewhen it involves one of our members. We track this through our SMI reportingmechanisms. The provider may report this either verbally or in writing. ThePennsylvania Childline phone number is 1-800-932-0313.Orientation and ongoing provider education concerning this policy occurs through theprovider manual, provider education and training processes, and on a one-to-one basis,as necessary with providers. SMIs that are considered serious are contained in theprovider benchmarking review for recredentialing purposes. This process is a part of thecomprehensive provider evaluation process (CPEP) and includes monitoring providerstandards of practice as well as their timely response in addressing incidents identified.III.H. Provider Cultural CompetencyAs stated in Section I.B, Community Care has a vision for an effective and accessiblesystem of behavioral health care that requires providers to be culturally competent. Toenhance cultural competency of network providers, Community Care:Assesses providers’ cultural competency.Presents a training session for providers in principles of cultural competence.Has developed outcomes measures related to the care provided in a culturallydiverse system.Assessment of cultural competency includes evaluation of the diversity of providers inthe network and their documentation of all member informational materials (includingaudiovisual materials, training documents, service pamphlets and radio or televisionpublic service announcements).Cultural competency is demonstrated by:Documentation that multi-linguistic populations have access to appropriatetranslators and, when a predetermined percentage of Community Care’smembership speaks a language other than English, to appropriate multi-linguisticwritten member materials.Documentation that member materials address the needs of special-servicepopulations.Documentation that materials are culturally sensitive and appropriate to the memberaudience.Providers’ cultural competency is evaluated using instruments and methods that areconsistent with cultural patterns and norms of the members being served. Theinstruments vary according to the specific cultural groups being surveyed. However, allinstruments evaluate whether the provider understands the culture of the communityCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 83
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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
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always be considered in light of th
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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
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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 80 and 81: III.E. Clinical Practice Guidelines
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
Page 128 and 129: . The provider will also receive a
Page 130 and 131: 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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