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Provider Manual and Alerts

The HealthChoices Provider Manual is designed to introduce you to Community Care and provide you with phone numbers as well as instruction regarding authorizations, billing, and quality of service.

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Provider Manual Full Version
Entire Manual 1.1 MB 216 pages PDF

Provider Manual By Chapter+ Expand All
+ Welcome
- Welcome
Welcome Chapter 110KB 11 pages PDF
Welcome to the Community Care HealthChoices Network
HealthChoices Key Contact Page
Guidelines for Obtaining Approval for In-Plan and Supplemental Services
+ I. About Community Care
- I. About Community Care
Chapter I 105KB 15 pages PDF
I.A Code of Ethics
I.B Cultural Competency Vision
I.C Overview of Quality Management
I.D Compliance with Fraud and Abuse Reporting
I.E Our Care Management Team
+ II. About Community Care HealthChoices Members
- II. About Community Care HealthChoices Members
Chapter II 175KB 30 pages PDF
II.A Member Rights and Responsibilities
II.B Member Help in Selecting Providers
II.C Member Satisfaction
II.D Member Behavioral Health Preventive Health Programs
II.E Member Complaint and Appeal Procedures
II.F Member Grievances
+ III. About Being a Community Care HealthChoices Provider
- III. About Being a Community Care HealthChoices Provider
Chapter III 200KB 33 pages PDF
III.A Practitioner Credentialing, Contracting, Recredentialing
III.B Facility/Organization Assessment, Contracting, Reassessment
III.C Confidentiality and Disclosure Policies
III.D Record Keeping Standards
III.E Clinical Practice Guidelines
III.F New Technologies
III.G Unusual Incidents/Significant Member Incident Reporting (Patient Safety)
III.H Provider Cultural Competency
III.I Comprehensive Provider Evaluation Process (CPEP)
III.J Provider Satisfaction
III.K Provider Education
III.L Provider Advisory Committee
+ IV. Providing Services to HealthChoices Network Members
- IV. Providing Services to HealthChoices Network Members
Chapter IV 95KB 11 pages PDF
IV.A Verifying Member Eligibility for HealthChoices Network Services
IV.B Medical Necessity (Level of Care) Criteria
IV.C Obtaining Approval to Provider Services (Outpatient Registration, Precertification, Authorization)
IV.D Standards for Member Access to Services (Appointments)
IV.E Coordination of Care, Referrals, Transition of Care to Other Providers
IV.F Care Management Services
+ Billing Manual
- Billing Manual
Billing Manual 180KB 23 pages PDF
+ Glossary of Terms and Abbreviations
- Glossary of Terms and Abbreviations
Glossary of Terms and Abbreviations 50KB 4 pages PDF
+ Appendices
- Appendices
Appendices 470KB 93 pages PDF
A.1 Fraud, Waste, and Abuse Compliance and Auditing Policies and Procedures
B.1 Consents for Release of Information Forms and for Physical Health/Behavioral Health Collaboration
C.1 Priority Populations
D.1 Behavioral Health Managed Care Organizations (BH-MCOs) Performance/Outcome Management System (POMs)
E.1 Companion Guide for Northeast Counties
F.1 Companion Guide for North Central Counties

Chapter 1101 of the Pennsylvania Code sets forth the Medical Assistance regulations and policies which apply to providers. Regulations specific to each type of provider are located in the separate chapters relating to each provider type. View Chapter 1101 of the Pennsylvania Code.

Throughout the year we issue Provider Alerts which are official updates to the main manual. Please print and save these updates and keep them with your manual. Alerts apply to all counties except where noted.

2012 Provider Alerts
PA3 Apr-16 Medicare Dual Eligibles - Inpatient Psychiatric Admissions [Allegheny] 50 KB PDF
PA2 Apr-4 Provider Online [Allegheny] 80 KB PDF
PA1 Mar-1 HealthChoices Rate Setting Policies 86 KB PDF
Erie County 30 KB PDF

The information in Provider Alerts prior to 2009 is included in the Provider Manual at the top of the page. The archive below is available for your convenience.

Archive of Provider Alerts
2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003