Billing Manual for Community Care Network Providers

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eing served and uses strategies to avoid breakdowns and pitfalls due to culturalinsensitivity in the provision of care. The Quality Management Department reviews allcomplaints received related to cultural competency of providers, conducts trendanalyses, and determines appropriate follow-up when needed. Providers’ commitmentis essential to our ongoing development of a responsive system of care.III.I. Comprehensive Provider Evaluation Process (CPEP)Community Care believes that a successful partnership with providers includescollaboration between Community Care and our provider network to improve the clinicaland quality care delivered to HealthChoices members. Community Care employsseveral methods to evaluate providers to ascertain and improve the quality of careprovided to members through the provider network. This process can only beaccomplished through the involvement, participation, and collaboration of providers. Italso ensures that Community Care begins this quality assessment from the time ofapplication for network inclusion. Quantitative and qualitative performance data arenecessary for a useful system of comprehensive provider evaluation.Goals of the CPEP include:Ensuring that every provider (both individual practitioners and facilities) is providingcare to members, which meet best practice clinical and quality standards.Ensuring providers’ care meets access standardsEnsuring that every provider is culturally competent to provide services to membersStriving to continually improve the practice standards of the provider network in bothurban and rural areas.Utilizing both qualitative and quantitative measures to provide feedback to providers,county (ies), oversight entities, OMHSAS, and other stakeholders to ensureappropriate care.Identifying areas for improvement with subsequent opportunities for correctiveaction.Identifying individual provider clinical practices in comparison to other providers.Ensuring a safe and healthy environment for members with appropriate attention tofamily/significant other involvement.Ensuring that providers practice within an environment conducive to recovery andresiliency principles.Obtaining feedback from members, families, and other stakeholders through avariety of forums.Providing select information to members, families, and other stakeholders.In addition, the CPEP creates opportunities for providers to: Internally monitor themselves. Review claim reports about service activity.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 84
Review claim reports compared to aggregate claims reports of like providers.Identify trends.Improve the safety of their clinical environment.Participate in the resolution of member complaints.Promote appropriate family involvement.Ensure financial stability within their organizations.Promote their internal processes within a quality improvement framework.Establish policies that support performance standards and quality of care issues.Promote best practices.Review current practices with other providers.Implement evidence based practices.The overall comprehensive provider evaluation process consists of several methods ofevaluation to meet the stated goals.These methods include:Credentialing/Facility Assessment and ongoing Recredentialing/FacilityReassessment.Compliance with Community Care Performance Standards.Compliance with IPRO data collection and improvement processes.Compliance with Evidence Based Practices.Evidence from medical record reviews.Trending of Significant Member Incidents (SMIs).Demonstrated compliance with mental illness/substance abuse (MISA) screenings,coordination of care standards, and domestic violence screenings.Evidence of compliance with submission of requested reports including BHRSreporting.Timely return of quality improvement plans.Cooperation with Consumer/Family Satisfaction Teams and interventions related tomember concerns.Claims-based Provider Benchmarking Reports.Complaint trends.Grievance trends.Licensure status change (Provisional).Identification of provider performance incidents, e.g., lack of adequate dischargeplanning, late submission of BHRS packets.Overall compliance with provider network contract.Results of Fraud, Waste and Abuse Department visits.The CPEP is the responsibility of the Provider Relations/Network Development, CareManagement, Customer Service, Quality Management, Provider Reimbursement, andCompliance Departments of Community Care and is managed through quality. Datafrom each method may occur at various times throughout the year, and providerCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 85
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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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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
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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
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Page 80 and 81: III.E. Clinical Practice Guidelines
Page 82 and 83: Community Care has developed a plan
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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
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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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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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