Billing Manual for Community Care Network Providers

IV.E.3 Transition of Care to another Community Care ProviderWhen a Community Care provider contract is terminated, Community Care may allowup to a 60 day transition of care period or through the acute phase of the disorder,whichever is less, for members under the terminated provider's care.IV.F. Care Management ServicesShould a member require other than routine outpatient services, he/she will be assignedto a care manager. The goals of Community Care’s care management program are to:Ensure members’ timely access to geographically convenient needed services.Ensure quality care at the least-restrictive, most cost-effective level.Ensure equitable access to care for members across the network, in the mostappropriate clinical setting and at the appropriate level of care.Ensure that care meets standards and quality criteria.Assess and correct for over utilization, under utilization, inefficiency, and delays inaccess to services.Ensure that services are culturally competent.Ensure that the member and family (if indicated) are involved in treatment planning.Ensure that behavioral health services result in positive outcomes for members.For routine outpatient services, the Community Care customer service representativewill ensure members’ timely access to geographically convenient services.Care Managers may not deny care. If a member’s behavioral health status does notmeet Medical Necessity Criteria for the level of care or the services do not meet ClinicalPractice Guidelines criteria, the service is reviewed by a Community Care professionaladvisor (peer reviewers).IV.F.2 Peer ReviewersCommunity Care contracts with board-certified psychiatrists and addiction specialists,some with subspecialty expertise in providing child and adolescent or geriatric care andwith state-licensed psychologists to serve as peer reviewers. Peer reviewers arethoroughly trained to evaluate whether proposed services meet quality criteria, MedicalNecessity Criteria, and Clinical Practice Guidelines criteria. Community Care peerreviewers perform the following services: Render objective decisions on the level of care (Medical Necessity) and theappropriateness and quality of care. Advise Community Care’s Chief Medical Officer and Quality Management and CareManagement Departments. Consult with providers on precertification and concurrent and post-service reviews.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 96