Billing Manual for Community Care Network Providers

For any questions about providing services to Community Care members, pleasecall the Provider Line at 1-888-251-2224 (24 hours a day/seven days a week).IV.A. Verifying Member Eligibility for HealthChoices Network ServicesCommunity Care strongly recommends that all providers verify with the member his/ herenrollment in HealthChoices. You can verify that an individual is eligible to receiveservices by calling the Provider Line at 1-888-251-2224. Due to the HealthChoicesBehavioral Health Expedited Enrollment initiative, it is critical that all providers checkEVS on any day in which services are being rendered.IV.B. Medical Necessity (Level of Care) CriteriaOn a member's initial visit you will evaluate the member and determine what behavioralhealth services you believe the member needs. However, before you provide theseservices, you must make sure the services meet Medical Necessity (Level of Care)Criteria in the applicable guideline.Community Care’s Care Management Department uses these criteria in determiningwhether to issue an authorization (preapproval, precertification) for service (See SectionIV.C).If the member’s clinical condition necessitates a level of care that is covered in theindividual’s benefit plan but that level of care is not available, the next highest coveredbenefit level of care will be authorized.Mental health Medical Necessity Criteria (Appendix T) may be obtained from:http://www.ccbh.com/providers/phealthchoices/medicalnecessityChemical dependency Medical Necessity Criteria, Pennsylvania Client PlacementCriteria (PCPC) may be obtained from: Department of Health, Bureau of Drug andAlcohol Programs, Room 929, Health and Welfare Building, Harrisburg, PA 17108 orfrom: http://www.ccbh.com/providers/phealthchoices/medicalnecessityAmerican Society for Addiction Medicine (ASAM) criteria may be obtained from:http://www.asam.org Patient Placement Criteria (PPC-2R) may also be obtained from:ASAM Publications Distribution Center 1-800-844-8948 or P.O. Box 101, AnnapolisJunction, MD 20701-0101.Some supplemental levels of care are not addressed in Appendix T. Community Carehas developed supplemental Medical Necessity Criteria for these levels of care. For acomplete list of these criteria, please visit Community Care’s website at:Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 88