Provider Bulletin | June 2010

Welcome to the June edition of the Provider Bulletin. In this edition, you will find useful information about enhanced member services, completing your residential summary, how to appeal a denied claim, upcoming training, and how to inform us of an open house.

Forward this bulletin to others in your organization who need to know this information. They are encouraged to sign up to receive it by email.

If you have any comments or questions, send us an email.

Enhanced Services

As a contracted provider in the Community Care Provider Network, you are prohibited from charging Community Care members, including their family members and friends, for any services or products unless written approval to provide an “enhanced service” is obtained from Community Care prior to the delivery of the service or product.

Enhanced services include any service or product that is not included in the member’s care plan or is an upgraded service or product. For example:

Example 1: A member’s care plan authorizes two hours of supportive home care services each day. The member’s mother would like the member to receive one additional hour each Friday and is willing to pay for the additional time. The additional time is considered an “enhanced service.”

Example 2: A member’s care plan funds the cost of a single room in an assisted living facility. The member wants to live in a larger, more expensive suite. The cost difference between the single room and the suite is considered an “enhanced service.”

Example 3: A member’s care plan authorizes the purchase of a generic product that will support his/her outcome. The member wants a more expensive, name-brand product. The cost difference is considered an “enhanced service.”

The contract between Community Care and the State of Wisconsin defines the conditions under which enhanced services may be purchased by or on behalf of the member. These conditions include the requirement that a Community Care member rights specialist must provide the member, member’s family, or friends with counseling to ensure that they understand what they are purchasing and to ensure that the purchase of any enhanced service is voluntarily. Additionally, Community Care must obtain a written statement signed by the member, Community Care, and the provider that details the financial responsibilities of each party. This documentation must be completed BEFORE any enhanced services or products are delivered.

The full explanation of enhanced services, begins on page 80 of the State’s MCO contract at http://dhs.wi.gov/ltcare/StateFedReqs/cy2010mcocontract.pdf.

Reminder! Complete Your Residential Summary

We recently sent you an assessment to help us identify the level of care you are able to provide at each of your facilities. Our care teams will use this information as a tool to identify the most appropriate placement for the members we serve.

Complete the Residential Summary and return it by email, fax 262-446-6707 or by mail at:

Community Care
Provider Management
1801 Dolphin Drive
Waukesha, WI 53186

Need another form? Download one at www.communitycareinc.org/ForProviders. If you have any questions, please call the Provider Hotline at 866-937-2783.

New Adult Family Home Certification Contact Info

As you know, Community Care is now responsible for completing all aspects of the certification process for 1-2 bed Adult Family Homes.

For your convenience, Community Care has now set up a phone number and email
address for you to call with your inquiries about AFH certification:

Phone: 414-902-2482
Email: AFH.Certification@communitycareinc.org

Are You Planning An Open House?

If you are having an open house, we want to hear about it! Email us your open house information:
• County location
• Facility name
• Size of facility (Number of beds and indicate AFH, CBRF, RCAC)
• Address
• Date
• Time
• Contact name & telephone number
• Brief description of your home

Once we receive the above information, we will notify the care teams of your open house. If you have any questions, send us an email.

Training Opportunities Listed On Community Care Website

There are many providers that must provide annual training to their staff. To make these training opportunities easier to find, we have developed a web page on the Community Care website listing upcoming training events. Find it at www.communitycareinc.org/ForProviders/training.htm. We encourage you and your staff to take advantage of these great opportunities.

If you have a training event you would like us to consider posting on our site, send us an email.

How To Appeal A Denied Claim

In the event that Community Care makes only a partial payment of a claim, or denies payment of a “clean claim,” the provider may appeal the decision. Do so by writing a letter marked “Appeal Request” and include the following information:
• Provider name
• Dates of service
• Date of billing
• Date of partial payment or denial
• Reason(s) claim merits consideration along with any supporting documentation

Mail the letter to:
Community Care
Claims Dept.
P.O. Box 341997
Milwaukee, WI 53234

The appeal must be submitted within 60 days of the date of the partial payment or denial. Community Care then has 45 days from receipt of the appeal to make a decision. If the provider does not agree with the decision by Community Care, the provider may appeal to the DHS within 60 days.

Refer to your contract for complete details of the appeal process.

Provider Claims Education Training Schedule

Community Care conducts claims education training to providers on a monthly basis. You are welcome to attend any of the sessions listed below. Current and new non-medical providers are welcome.

Waukesha County Site
When: June 17, 2010 and July 15, 2010
Time: 1:00 to 3:00 p.m.
Where: Community Care, 1801 Dolphin Drive, Waukesha, WI 53186

Additional training sessions will be provided in other counties on future dates. If you have any questions, or would like to sign up for a session, send us an email.