Billing Manual for Community Care Network Providers

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dialogue and intervention may occur when trends are identified. Specific providerinformation is retained through the Quality Management Department. Community Careprovides feedback, through various quality activities to providers on an ongoing basis. Inaddition, Community Care analyzes aggregate network performance, makinginformation available to providers through articles, committees, public forums, andindividual provider meetings or site visits.Certain information identified as a result of the comprehensive provider evaluationprocess related to individual providers may fall under protected, peer reviewed, andprivileged information and will not be shared publicly. This information, however, will beshared with specific Community Care county contractors and OMHSAS.III.J. Provider SatisfactionProvider satisfaction is important to Community Care and we have multiple ways inwhich providers can express both their satisfaction and dissatisfaction with ouroperations.We contract with an outside survey company to conduct an Annual Provider SatisfactionSurvey. The survey tool is designed to assess provider satisfaction in a variety of areasincluding (but not limited to): utilization management, quality management, providerrelations, complaint & grievance procedures, care management, customer service, andclaims.Providers are encouraged to take the time to complete the survey. We welcome yourcomments and feedback on the services you have received from our staff and areinterested in how we can improve provider services. The results are reviewed bothinternally and with the Quality and Care Management Committee. The Committeeidentifies areas for improvement and interventions are developed to increasesatisfaction in those targeted areas.If you are dissatisfied with any aspect of Community Care's operations, we urge you toexpress your concern by calling the Community Care Provider Line (1-888-251-2224). Ifan issue cannot be resolved informally, you may lodge a formal complaint. You mayexpress your provider complaint orally or in writing. If the complaint cannot be resolvedimmediately, Community Care will send a resolution letter within 30 days.Community Care also utilizes the formal Provider Advisory Committee to receivefeedback from Providers. The Committee meets quarterly and Providers areencouraged to participate. If you are interested in becoming involved in this committeeplease call the Provider Line at 1-888-251-2224 to get more details.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 86
III.K. Provider EducationCommunity Care offers provider training on a variety of topics, with a focus ondeveloping skills in managing care, meeting and exceeding performance standards, andensuring cultural competence in delivery of behavioral healthcare services throughoutthe network. The person who will receive mailings about these sessions is thedesignated contact person identified in your network application. Please check with yourCommunity Care provider relations representative for the name of this person or if youneed to change the contact person (key contact).III.L. Provider Advisory CommitteeAll Community Care providers are eligible, welcome, and urged to participate in theCommunity Care Provider Advisory Committee in their local area. These committeesare designed to allow providers to give feedback to Community Care on a regular basis.There are other Community Care committees that include providers. If you would like toparticipate, please call the Community Care Provider Line (1-888-251-2224).IV. Providing Services to HealthChoices Network MembersCommunity Care has developed specific procedures for providers to follow in providingbehavioral health services to HealthChoices members. These procedures: Verify that the services are covered. Ensure that every member receives the level of care that he/she requires. Provide member services in a seamless fashion. Ensure that care meets quality standards.The following sections detail procedures for providing services. As a part of CommunityCare's commitment to quality improvement, these procedures are updated as needed.A. Verifying Member Eligibility for HealthChoices Network ServicesB. Medical Necessity (Level of Care) CriteriaC. Obtaining Authorizations (Registration, Precertification)D. Standards for Member Access to Services (Appointments)E. Coordination of Care, Referrals, Transition of Care to Other ProvidersF. Care Management ServicesIn addition, Community Care has a policy to review proposed new treatments forbehavioral health disorders. To submit a new technology request for review, talk with aCommunity Care care manager. The care manager will forward your request toCommunity Care's Chief Medical Officer for review.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 87
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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
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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
Page 78 and 79: Medication(s) that have been prescr
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
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
Page 132 and 133: A Facility or group practice name,
Page 134 and 135: 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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