Billing Manual for Community Care Network Providers

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Billing ManualCommunity Care Behavioral Health Organization (Community Care) has designed aclaims payment process that ensures prompt and accurate payment for services. In thishandbook you will find requirements and explanations for each component of the billingprocess.Prompt and accurate claims payment is one of the most important tasks of anymanaged care company and Community Care is committed to excelling in this area.Community Care’s ability to pay claims is directly related to the manner in which theprovider bills for services. If claim forms are incomplete or incorrect, claims for servicesthat should be reimbursed may be denied. Providers should pay careful attention to theprocesses used for capturing services and billing since a healthy cash flow is critical toany organization’s ability to provide service.This billing manual is prepared as a guide to policies and procedures for individualpractitioners, group practices, programs, facilities, and hospitals to reference whenbilling Community Care for HealthChoices members.Community Care endeavors to make billing and claims payment as straightforward aprocess for providers as possible. Community Care’s Provider ReimbursementDepartment is available for questions by calling 1-888-251-2224 and following theprompts to Provider Reimbursement. The Provider Reimbursement line is staffed from8:30 a.m.-12 p.m., and from 1- 5:00 p.m., Monday-Friday. If you call between 12 and 1p.m., you will receive a message advising you that the Provider Reimbursement line isclosed. You can check the status of your claim on Provider Online or call the ProviderReimbursement line back during the hours of operation. Questions related to claimsMUST be directed to the Community Care Provider Reimbursement Department.The essentials of completing claim forms are related to ensuring that all of the blocks onthe specific claim form are populated based on the instructions provided in this manual.It is important to note that for the HealthChoices program, these instructions are basedon Medical Assistance requirements rather than on the usual standards for billingcommercial and other insurance payors.Before Providing CareChecking EligibilityCommunity Care manages the behavioral health care benefits for HealthChoicesmembers in your area. Members must be Medicaid eligible to enroll with HealthChoices.Members are instructed to carry their Medicaid Access Card for eligibility verification.As a provider, it is important to ensure that a client is a current HealthChoices memberbefore providing services. No matter what authorization you receive, if the memberCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 98
to whom you provide services is not eligible for Medical Assistance on the dateservices are rendered, we will not be able to pay you.You can verify eligibility in a number of ways. You must use your 13-digit PROMISeProvider Identification Number. You can check eligibility directly by calling 1-800-766-5387. Swipe the member’s Access Card.Listed below is the website related to obtaining the EVS software:EVS software – approved commercial vendors of EVS software appear on the OMAPwebsite athttp://www.dpw.state.pa.us/provider/doingbusinesswithdpw/softwareandservicevendors/eligibilityverificationinformation/index.htmPlease remember that EVS is utilized to determine if a member is eligible and cannotbe utilized as the main source for TPL information or confirmation.Obtaining AuthorizationsAn authorization is an agreement that the care you want to provide to a specificmember meets medical necessity for that level of care. It is not a promise to pay aclaim.While most services require an authorization or registration notification for claimspayment, not all services require pre-approval or precertification. (Refer to theGuidelines for Obtaining Approval for In-Plan and Supplemental Services).The care management clinical staff is available 24 hours a day/seven days a week toprovide precertification or pre-approval for urgent services. For non-urgent services,care managers are available Monday through Friday during the hours of 8:30 a.m. to5:00 p.m. The Care Management Department is available at any time by calling 1-888-251- 2224 and selecting the appropriate options from the menu. Community Care’safter-hours coverage ensures providers will always have access to clinical personnel forclinically urgent situations.While an authorization number is generated at the time of approval, this number is notrequired to appear on the billing form for consideration of payment. Our informationsystem can match your bill to the appropriate authorization when you follow theprocedures outlined in the section of this manual entitled “Completing & SubmittingClaim Forms”.An authorization is NOT a guarantee of payment. All of the billing aspects of the servicemust be correct for the claim to be paid including meeting the timely file submissionguidelines.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 99
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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
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II.D.1e EvaluationIndividuals parti
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II.D.2b GoalsThe goals of Community
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II.D.3 Providers’ Role in the Pre
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Community Care has a total of 30 ca
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Department of Health and provide in
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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
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
Page 68 and 69: contracting, performance evaluation
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 86 and 87: dialogue and intervention may occur
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
Page 94 and 95: ORA member expresses a readiness fo
Page 96 and 97: IV.E.3 Transition of Care to anothe
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
Page 136 and 137: The medical director or his/her des
Page 138 and 139: The privacy officer will review the
Page 140 and 141: collection and use of member identi
Page 142 and 143: Protection of information disclosed
Page 144 and 145: If a member is granted access to re
Page 146 and 147: 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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