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Manual for
Community Care
Network Providers
Community Care Behavioral Health
Organization
339 Sixth Avenue
Suite 1300
Pittsburgh, PA 15222
Provider Line: 1-888-251-CCBH (2224)
Website: www.ccbh.com
Welcome
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 1
Dear Network Provider,
Welcome to Community Care Behavioral Health Organization (Community Care).
This Provider Manual is designed to introduce you to Community Care and
provide you with contact numbers; instructions regarding authorizations, billing,
and quality of service; and access to our performance standards.
As this Provider Manual is utilized for all of Community Care’s HealthChoices
contracts, we publish a companion guide within the manual for any contract
where there are changes related to specific counties (please see Appendix E and
Appendix F). The companion guide will identify additions and deletions to specific
sections of the manual related to specific counties. Please be sure to review the
appropriate document(s) in conjunction with this manual.
We hope that you find this manual to be clear and easy to follow. If you have any
questions, please call your assigned provider representative. Provider
representatives’ contact information can be found at
http://www.ccbh.com/providers/networkdevelopment/providerreps or call our
provider toll-free telephone line, 1-888-251-2224, for assistance. The Provider
Line answers 24 hours a day/seven days a week.
We look forward to working with you.
Sincerely,
Kristin Burns
Senior Director, Network Management
Community Care
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 2
Welcome to the Community Care HealthChoices Network
Community Care is pleased to welcome you to our network. Since 1999, we have
worked to serve HealthChoices* members and to create and support a strong
network of providers and quality care. Our knowledge of managing care for highrisk populations combined with stakeholder input regarding program
development has been the key to the successful management of our members’
care.
Community Care’s mission is to improve the health and well-being of the
community by delivering effective, high-quality, and accessible behavioral health
services in a nonprofit partnership with public agencies, experienced local
providers, and involved members and their families.
Community Care values:
• Excellence in customer service.
• Collegial relationships with managed care partners.
• Decision making based on criteria and data.
• Effective individualized care and service.
• Collaborative relationships with customers, stakeholders, and providers.
• Continuous quality improvement.
This manual contains information about Community Care’s commitment to acting
responsibly and ethically and meeting the highest standards of care for
members. It describes who we are, our HealthChoices members, what you need
to know as a network provider, and our policies and procedures for providing
care. This manual also contains instructions for claims submission (see the
Billing section).
Information is always changing; please tell us about any changes in your contact
information or services. And watch for Provider Alerts from us; Provider Alerts
amend the content of this manual and your contractual obligations.
We welcome your suggestions about how Community Care can improve our
service to you. Together we can present our members with a “seamless” system
of high-quality behavioral health services and contribute to the communities and
regions in which we work.
*Community Care manages behavioral health services for Medicaid recipients (the program is
known in Pennsylvania as HealthChoices) in counties throughout the Commonwealth of
Pennsylvania.
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 3
HealthChoices Contact Information
Corporate Office:
Community Care Behavioral Health Organization
339 Sixth Avenue
Suite 1300
Pittsburgh, PA 15222
Telephone: 412-454-2120; 1-866-415-1707; TTY: 1-877-877-3580
Fax: 1-412-454-2177
Provider Reference Materials:
Appendix T for Mental Health Medical Necessity Criteria may be obtained from:
http://www.ccbh.com/providers/phealthchoices/medicalnecessity
Chemical Dependency Medical Necessity Criteria, Pennsylvania Client
Placement Criteria (PCPC) may be obtained from:
http://www.ccbh.com/providers/phealthchoices/medicalnecessity
Department of Health, Bureau of Drug and Alcohol Programs, Room 929, Health
and Welfare Building, Harrisburg, PA 17108 or from
American Society for Addiction Medicine (ASAM) criteria may be obtained from:
www.asam.org Patient Placement Criteria (PPC-2R) may be obtained from
ASAM Publications Distribution Center, 1-800-844-8948, or P.O. Box 101,
Annapolis Junction, MD 20701-0101.
Provider Lines
Provider Phone Line (Answers 24/7)
Claims Questions
Outpatient Registration (OPR) Authorization Forms
Fraud and Abuse Hotline
1-888-251-2224
opt 1, opt 2, opt 1
1-877-371-0014
1-866-445-5190
Customer Service Lines for Members (24/7) by County:
Adams
Blair
Carbon
Clarion
Columbia
Forest
Juniata
Lycoming
Monroe
Pike
Snyder
Tioga
Wayne
1-866-738-9849
1-855-520-9715
1-866-473-5862
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-855-520-9787
1-866-473-5862
1-866-473-5862
1-866-878-6046
1-866-878-6046
1-866-878-6046
Allegheny
Bradford
Centre
Clearfield
Elk
Huntingdon
Lackawanna
McKean
Montour
Potter
Sullivan
Union
Wyoming
1-800-553-7499
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-668-4696
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-668-4696
Berks
Cameron
Chester
Clinton
Erie
Jefferson
Luzerne
Mifflin
Northumberland
Schuylkill
Susquehanna
Warren
York
1-866-292-7886
1-866-878-6046
1-866-622-4228
1-855-520-9787
1-855-224-1777
1-866-878-6046
1-866-668-4696
1-866-878-6046
1-866-878-6046
1-866-878-6046
1-866-668-4696
1-866-878-6046
1-866-542-0299
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 6
Clinical Fax by County:
Adams
Blair
Carbon
Clarion
Columbia
Forest
Juniata
Lycoming
Monroe
Pike
Snyder
Tioga
Wayne
1-866-418-0366
1-855-473-2359
1-866-901-8367
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-855-473-2360
1-866-901-8367
1-866-901-8367
1-866-294-3935
1-866-294-3935
1-866-294-3935
Allegheny
Bradford
Centre
Clearfield
Elk
Huntingdon
Lackawanna
McKean
Montour
Potter
Sullivan
Union
Wyoming
1-888-251-0087
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-284-9184
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-284-9184
TTY for people who are Deaf/Hard-of-Hearing
Spanish Line
Autism Support Line
PA Child Abuse Hotline
Berks
Cameron
Chester
Clinton
Erie
Jefferson
Luzerne
Mifflin
Northumberland
Schuylkill
Susquehanna
Warren
York
1-877-877-3580
1-866-229-3187
1-866-415-1708
1-800-932-0313
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 7
1-866-418-0366
1-866-294-3935
1-888-589-6559
1-855-473-2360
1-855-892-8495
1-866-294-3935
1-866-284-9184
1-866-294-3935
1-866-294-3935
1-866-294-3935
1-866-284-9184
1-866-294-3935
1-866-418-0366
Guidelines for Obtaining Approval for In-Plan and Supplemental Services
Mental Health
Service
Emergency
Evaluation
Crisis Services:
Mobile, Telephone,
Walk-In
Psychiatric
Outpatient
Evaluation or Initial
Non-MD evaluation
Best Practice / Life
Domain Evaluation2
Authorization
Type
Authorization
via Request
Center
submission
None
Notification;
Approved
BHRSCA
Providers and
BHRSCA
prescribers
submit via
Facsimile
Transmittal
Request Form
Limits/Exclusions/Definitions
Hospital not reimbursed separately if patient is
admitted within 24 hours to the evaluating facility.
Requests may be made up to 30 days before and 60
days after the start of service.
Child: State-approved Best Practices format is
required for Behavioral Health Rehabilitation Services
for Children and Adolescent (BHRSCA) services and
RTF.
In some parts of the Commonwealth there is very
limited access to licensed psychologists and nonlicensed providers sometimes complete evaluations
without any face-to-face evaluation by the licensed
psychologist. Community Care will allow this practice
to continue. However, we encourage licensed
prescribers to continue to participate in all Best
Practice evaluations and re-evaluations unless access
issues make that option impossible.
Please note that, if doctoral or master's level
clinicians who are non-prescribers are conducting parts
of or the entire BP evaluation, these individuals must
be designated by and directly supervised by the
licensed prescriber. Please refer to Chapter 41 of the
PA Code for Psychologists by the State Board of
Psychology.
Community Care advocates that prescribers review the
case w/the doctoral or master’s level clinicians who are
conducting parts of or the entire evaluation. Request
Form must be submitted following the initial evaluation;
not to exceed the timely filing limits for Claims
submission for the member’s product coverage.
Concurrent: Request Form must be submitted
following the updated evaluation Request; not to
exceed the timely filing limits for Claims submission for
the member’s product coverage.
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 8
Outpatient Therapy1 Annual
Registration
Only
MD Outpatient
Medication Check
RN Outpatient
Medication Check1
None
Service
Coordination:
•Intensive Case
Management
•Resource
Coordination
•Blended Case
Management
Family-Based
Mental Health
Services
Authorization
via Request
Center
submission
Annual
Registration
Only
Precertification
Initial: Registration must be submitted following the
initial outpatient visit; not to exceed the timely filing
limits for Claims submission for the Member’s product
coverage.
Concurrent: Registration must be submitted prior to
the expiration of the initial annual registration period;
not to exceed the timely filing limits for Claims
submission for the member’s product coverage.
REFER TO THE BILLING SECTION FOR TIMELY
FILING LIMITS FOR EACH HEALTHCHOICES
PRODUCT.
—
Initial: Registration must be submitted following the
initial outpatient visit; not to exceed the timely filing
limits for Claims submission for the member’s product
coverage.
Concurrent: Registration must be submitted prior to
the expiration of the initial annual registration period;
not to exceed the timely filing limits for Claims
submission for the member’s product coverage.
REFER TO THE BILLING SECTION FOR TIMELY
FILING LIMITS FOR EACH HEALTHCHOICES
PRODUCT
Unit definition: 1 unit = 15 minutes.
Requests may be made up to 30 days before and 60
days after the start of service.
Unit definition: 1 unit = 15 minutes.
Providers send/fax precert to their designated care
manager who reviews and, if case meets medical
necessity for the service, authorizes. The standard
review schedule is to complete a Continued Stay
Review at month 3 then again at month 6. The final
review (Discharge Review) is completed within 5
business days of discharging the client from treatment.
Of note, care managers always reserve the right to
authorize and schedule reviews at their discretion
based on such concerns as poor progress in treatment
or high risk cases that require more care manager
involvement and/or more frequent review.
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 9
Psychological
Testing/
Neuropsychological
Testing
Electroconvulsive
Therapy
Non-Acute Partial
Hospitalization
Acute Partial
Hospital
Residential
Treatment Facility
Behavioral Health
Rehabilitative
Services (BHRS)2
Inpatient Admission
Clozaril
(Monitoring/Evaluati
on and Support
Services)1
Psychiatric
Rehabilitation; SiteBased, Mobile,
Clubhouse
Peer Support
Multi-systemic
Therapy (MST)
Precertification;
Facsimile
Transmittal
Request Form
Precertification
for Outpatient
only
Notification;
Facsimile
Transmittal
Request Form
Telephonic
Precertification
Precertification
Precertification
Precertification
exempt for
Medicare
Primary
Annual
Registration
Only
Precertification;
Facsimile
Transmittal
Request Form
Notification;
Facsimile
Transmittal
Request Form
Mail
Child or Adolescent: Authorized by testing group,
peer review.
Adult: Authorized by test, peer review.
Peer review.
Limit of 3 hours minimum to 6 hours maximum per day.
Limit of 3 hours minimum to 6 hours maximum per day.
Based on clinical necessity.
Re-evaluation required every 90 days.
Authorized by specific procedure; Community Care
care manager to be invited to all interagency service
planning team meetings.
Packet is due one week after the ISPT meeting
Based on medical necessity criteria.
Requires diagnoses on all 5 Axes; no V-codes
Notification of admissions and within 30 days of
discharge for Medicare Primary.
Initial: Registration must be submitted following the
initial outpatient visit; not to exceed the timely filing
limits for claims submission for the member’s product
coverage.
Concurrent: Registration must be submitted prior to
the expiration of the initial annual registration period;
not to exceed the timely filing limits for claims
submission for the member’s product coverage.
REFER TO THE BILLING SECTION FOR TIMELY
FILING LIMITS FOR EACH HEALTHCHOICES
PRODUCT
Based on clinical necessity.
Initial: Two months authorized at pre-certification.
Continued Stay: Three months authorized at
continued stay.
Unit definition: 1 unit = 15 minutes.
Members must be age 18 or older or age 22 if in
Special Education.
Maximum six months authorized for each request.
Packet is due one week after the ISPT meeting.
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 10
Functional Family
therapy (FFT)
Multidimensional
Treatment Foster
Care (MTFC )
Mobile Mental
Health Treatment
(MMHT)
Tobacco/Smoking
Cessation
1
2
Mail
Packet is due one week after the ISPT meeting.
Mail
Packet is due one week after the ISPT meeting.
Notification;
Facsimile
Transmittal
Request Form
Members must be age 21 or older.
None
Individual and group delivery.
Maximum 30 units per 90 day authorization time frame.
Based on clinical necessity and will be reviewed every
90 days.
Maximum 70 units per year, per member/provider. The
maximum unit is calculated by the total number of
combined units (individual and/or group).
Outpatient registration (OPR): Annual registration of Member required
Includes mental health, mental retardation, and chemical dependency services
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 11
Guidelines for Obtaining Approval for In-Plan and Supplemental Services
Chemical Dependency
Service
Emergency
Evaluation
Psychiatric
Outpatient
Evaluation or
Initial Non-MD
Evaluation
Outpatient
Therapy1
Methadone
Maintenance
(Outpatient)1
Authorization
Type
None
Annual
Registration
Only
Annual
Registration
Only
Limits/Exclusions/Definitions
For a hospital, not reimbursed separately if
patient is admitted within 24 hours to the
evaluating facility.
Initial: Registration must be submitted following
the initial outpatient visit; not to exceed timely
filing limits for claims submission for the
member’s product coverage.
Concurrent: Registration must be submitted
prior to the expiration of the initial annual
registration period; not to exceed the timely filing
limits for claims submission for the member’s
product coverage.
REFER TO THE BILLING SECTION FOR
TIMELY FILING LIMITS FOR EACH
HEALTHCHOICES PRODUCT
Unit definition:
Bundled = 1 week (methadone and treatment)
Unbundled = 1 day (methadone only)
Initial: Registration must be submitted following
the initial outpatient visit; not to exceed the timely
filing limits for claims submission for the
member’s product coverage.
Concurrent: Registration must be submitted
prior to the expiration of the initial annual
registration period; not to exceed the timely filing
limits for claims submission for the member’s
product coverage.
Intensive
Outpatient
Therapy
Authorization
via Request
Center
submission
REFER TO THE BILLING SECTION FOR
TIMELY FILING LIMITS FOR EACH
HEALTHCHOICES PRODUCT
Must meet PCPC or ASAM for adolescents.
Requests may be made up to 30 days before
and 60 days after the start of service.
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 12
Non-Acute Partial
Hospitalization
Acute Partial
Hospitalization
Notification via
Facsimile
Transmittal
Request Form
Precertification
Must meet PCPC or ASAM for adolescents; at
least 3 visits per week with a minimum of 10
hours per week.
Must meet PCPC or ASAM for adolescents; at
least 3 visits per week with a minimum of 10
hours per week.
Must meet PCPC or ASAM for adolescents for
level 2B.
Must meet PCPC or ASAM for adolescents for
Level 4B.
Requires diagnoses on all 5 Axes; no V-codes.
Must meet PCPC or ASAM for adolescents for
level requested.
Halfway House
Precertification
Medically
Managed
Rehabilitation
Non-Hospital
Residential
Rehabilitation (3B;
short-term or 3C;
long term)
Medically
Managed
Detoxification
Non-Hospital
Detoxification
Precertification
Drug & Alcohol
Case
Management
(ICM/RC)
Authorization
via Request
Center
submission
Unit definition: 1 unit = 15 minutes.
Drug & Alcohol
Level of Care
Assessment
Authorization
via Request
Center
submission
Unit definition: 1 unit = 15 minutes.
1
Precertification
Precertification
Must meet PCPC for Level 4A.
Requires diagnoses on all 5 Axes; no V-codes.
Precertification
Must meet PCPC for Level 3A.
Requests may be made up to 30 days before
and 60 days after the start of service.
Requests may be made up to 30 days before and
60 days after the start of service.
Outpatient registration (OPR): Annual registration of Member required
Community Care Provider Manual | 1-888-251-CCBH | © 2014 All Rights Reserved | Page 13