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Contra Costa Health Services

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Provider Manual

CCHP Provider Manual

Appendices:

APPENDIX	TITLE
A	Abuse Reporting Forms: Child Abuse Instructions Child Abuse Report Domestic Violence Legal Requirements for Reporting Elder Abuse
B	Advanced Health Care Directive (English/Spanish)
C	Case Management Referral: Form Brochures - Provider Brochures - Member Minor Consent Form - Transportation-NMT
D	Claims: Corrected Claim Submission Guideline Appeal and Dispute Form Tracer Form
E	Confidential Morbidity Report
F	Contracted Hospitals – Hospitals Listing by City
G	Disease Management Referral Form
H	Fraud/Waste and Abuse Training for Providers
I	Pharmacy: Medication - Prior Authorization Request Request for Formulary Review
J	Member Services: Member Grievance and Appeal Form (English \| Spanish) Member ID cards \| Sample Member Rights (English \| Spanish) Member Consent for Provider to File an Appeal (English \| Spanish \| Chinese) List of Member Rights and Responsibilities (English \| Spanish)
K	Behavioral Health Evaluation Behavioral Health Referral for Child Behavioral Health Referral for Adult
L	CHDP Billing
M	Prior Authorization Request (PA) Form Prior Authorization Request/Referral (PA) Form – Bariatric Bypass Minor Consent Form Transportation-NEMT Disclosure of UM Criteria or Guidelines Request Form Physician Certification Statement (PCS) for NEMT
N	Provider and Member Call Centers
O	Provider Complaint Form
P	Seniors and Persons with Disabilities Cultural Sensitivity Training
Q	WIC Referrals: Pregnant Postpartum/Breastfeeding Woman Pediatric Referral
R	CPN PCP Orientation CPN Specialist Orientation CPN Urgent Care Orientation CPN Organizational Provider Orientation CCRMC Orientation

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