Billing Manual for Community Care Network Providers

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Guidelines for Obtaining Approval for In-Plan and Supplemental ServicesMental HealthServiceEmergencyEvaluationCrisis Services:Mobile, Telephone,Walk-InPsychiatricOutpatientEvaluation or InitialNon-MD evaluationBest Practice / LifeDomain Evaluation 2AuthorizationTypeNotification viaFacsimileTransmittalRequest FormNoneNotification;ApprovedBHRSCAProviders andBHRSCAprescriberssubmit viaFacsimileTransmittalRequest FormLimits/Exclusions/DefinitionsHospital not reimbursed separately if patient isadmitted within 24 hours to the evaluating facility.Fax within 60 days after service.Child: State-approved Best Practices format isrequired for Behavioral Health Rehabilitation Servicesfor Children and Adolescent (BHRSCA) services andRTF.In some parts of the Commonwealth there is verylimited access to licensed psychologists and nonlicensedproviders sometimes complete evaluationswithout any face-to-face evaluation by the licensedpsychologist. Community Care will allow this practiceto continue. However, we encourage licensedprescribers to continue to participate in all BestPractice evaluations and re-evaluations unless accessissues make that option impossible.Please note that, if doctoral or master's levelclinicians who are non-prescribers are conducting partsof or the entire BP evaluation, these individuals mustbe designated by and directly supervised by thelicensed prescriber. Please refer to Chapter 41 of thePA Code for Psychologists by the State Board ofPsychology.Community Care advocates that prescribers review thecase w/the doctoral or master’s level clinicians who areconducting parts of or the entire evaluation. RequestForm must be submitted following the initial evaluation;not to exceed the timely filing limits for Claimssubmission for the member’s product coverage.Concurrent: Request Form must be submittedfollowing the updated evaluation Request; not toexceed the timely filing limits for Claims submission forthe member’s product coverage.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 8
Outpatient Therapy 1MD OutpatientMedication CheckRN OutpatientMedication Check 1ServiceCoordination:Intensive CaseManagement/ResourceCoordination/Blended CaseManagementFamily-BasedMental HealthServicesAnnualRegistrationOnlyNone —AnnualRegistrationOnlyNotification viaFacsimileTransmittalRequest FormPrecertificationInitial: Registration must be submitted following theinitial outpatient visit; not to exceed the timely filinglimits for Claims submission for the Member’s productcoverage.Concurrent: Registration must be submitted prior tothe expiration of the initial annual registration period;not to exceed the timely filing limits for Claimssubmission for the member’s product coverage.REFER TO THE BILLING SECTION FOR TIMELYFILING LIMITS FOR EACH HEALTHCHOICESPRODUCT.Initial: Registration must be submitted following theinitial outpatient visit; not to exceed the timely filinglimits for Claims submission for the member’s productcoverage.Concurrent: Registration must be submitted prior tothe expiration of the initial annual registration period;not to exceed the timely filing limits for Claimssubmission for the member’s product coverage.REFER TO THE BILLING SECTION FOR TIMELYFILING LIMITS FOR EACH HEALTHCHOICESPRODUCTUnit definition: 1 unit = 15 minutes.Initial: Registration must be submitted within 30 daysof the initial evaluation.Concurrent: Registration must be submitted within 30days before or after the current authorization end date.Unit definition: 1 unit = 15 minutes.Providers send/fax precert to their designated caremanager who reviews and, if case meets medicalnecessity for the service, authorizes. The standardreview schedule is to complete a Continued StayReview at month 3 then again at month 6. The finalreview (Discharge Review) is completed within 5business days of discharging the client from treatment.Of note, care managers always reserve the right toauthorize and schedule reviews at their discretionbased on such concerns as poor progress in treatmentor high risk cases that require more care managerinvolvement and/or more frequent review.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 9
Page 5 and 6: APPENDIX A.2. Confidentiality 130AP
Page 7: Clinical Fax by County:Adams 1-866-
Page 11 and 12: Functional Familytherapy (FFT)Multi
Page 13 and 14: Non-Acute PartialHospitalizationNot
Page 15 and 16: I.A. Code of EthicsCommunity Care
Page 17 and 18: esources and evaluated on their pro
Page 19 and 20: Confidentiality policies including
Page 21 and 22: Within 30 minutes for urban areas.W
Page 23 and 24: I.E. Care Management Team“Advocat
Page 25 and 26: In order to serve special populatio
Page 27 and 28: Psychiatric Rehabilitation Clubhous
Page 29 and 30: always be considered in light of th
Page 31 and 32: 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
Page 45 and 46: An explanation of the grievance pro
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
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The following sections provide info
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members, practitioners are asked to
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Accreditation of Healthcare Organiz
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III.B.4 Facility ReassessmentFacili
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present relevant information, and t
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contracting, performance evaluation
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the implementation and application
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III.C.4 Ability to Give Informed Au
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When such disclosure to health care
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Practitioners are informed of the r
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Medication(s) that have been prescr
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III.E. Clinical Practice Guidelines
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Community Care has developed a plan
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eing served and uses strategies to
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dialogue and intervention may occur
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For any questions about providing s
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If you, as a Community Care provide
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When the precertification is for se
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ORA member expresses a readiness fo
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IV.E.3 Transition of Care to anothe
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Billing ManualCommunity Care Behavi
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Even though an authorization may be
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Timely File requests are to be mail
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Provide an alternative to the use o
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Required Claim FieldsIn the followi
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24C EMG Not required24D Procedure C
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17 Discharge Status Required forINP
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67a-q Diag. Code Required68 Unlabel
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• Explanation of Benefits (EOB) i
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Many of the services covered by Com
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Community Care Behavioral Health Or
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Community Care Procedure Code: The
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C/FST: Consumer/Family Satisfaction
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Medicaid/Medical Assistance identif
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APPENDICESAPPENDIX A.1. Fraud, Wast
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. The provider will also receive a
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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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