Billing Manual for Community Care Network Providers

http://www.ccbh.com/providers/phealthchoices/medicalnecessityIV.C. Obtaining Approval to Provider Services (Outpatient Registration,Precertification, Authorization)Even though you have determined that the services you intend to provide meet MedicalNecessity (Level of Care) Criteria, you cannot be paid for any service unlessCommunity Care has agreed with the determination and has given you approval toprovide the service. Approval is an agreement between you and Community Care thatthe care you plan to provide to a specific member meets the applicable MedicalNecessity Criteria.Depending on the services you plan to provide to a member, you need to:Register outpatient services with Community Care.Obtain precertification (preapproval) for services.Obtain authorization.The Guidelines for Obtaining Approval for In-plan Services at the front of this ProviderManual list whether authorization, outpatient registration, or precertification is requiredto receive approval to perform the service. The forms and steps for registration orprecertification are listed below.You may also reference the fee schedule attached to your contract for bothapproval and billing rules.For Coordination of Benefits (COB) when Community Care is the secondary payer,Community Care must be notified telephonically upon a member’s admission to any ofthe following levels of care: (i) Inpatient Mental Health; (ii) Acute Partial Mental Health(iii) Medically Managed and Medically Monitored Inpatient Detoxification (4A & 3A); (iv)Medically Monitored Short Term and Long Term Residential Rehabilitation (3B & 3C); or(v) Halfway House. Providers must also complete and fax the Coordination of BenefitsPrimary Insurance Discharge Notification Form to Community Care within five businessdays of the member’s discharge date in order to avoid any reimbursement problems.PLEASE NOTE: Receiving authorization is not a promise that the claim will bepaid (other criteria must be met). Refer to the Billing Section of this ProviderManual.IV.C.1 Outpatient Registration ProcedureCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 89