Member Handbook for Parkland KIDSfirst and Parkland CHIP ...

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Type of Benefit Description of Benefit Limitations Co-Pay (facility technical component) delivery and after 96 hours following an uncomplicated • Laboratory and pathology services (facility technical component) delivery by caesarian section • Machine diagnostic tests (EEGs, EKGs, etc) • Oxygen services and inhalation therapy • Radiation and chemotherapy • Access to DSHSdesignated Level III perinatal centers or hospitals meeting equivalent levels of care • In-network or out-ofnetwork facility for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section • Hospital, physician and related medical services, such as anesthesia, associated with dental care. • Surgical implants • Other artificial aids including surgical implants. • Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit. Transplants Medically necessary services include: • Using up-to-date FDA guidelines, all nonexperimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell PKF-M100708R 11 • Requires authorization • No Co-pays for CHIP or CHIP Perinate Newborn Members
Type of Benefit Description of Benefit Limitations Co-Pay transplants, including donor medical expenses Skilled Nursing Facilities (Includes Rehabilitation Hospitals) Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center Medically necessary services include, but are not limited to, the following: • Semi-private room and board • Regular nursing services • Rehabilitation services • Medical supplies and use of appliances and equipment furnished by the facility Medically necessary services include, but are not limited to, the following services provided in a hospital clinic, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: • X-ray, imaging, and radiological tests (technical component) • Laboratory and pathology services (technical component) • Machine diagnostic tests • Ambulatory surgical facility services • Drugs, medications and biologicals • Casts, splints, dressings • Preventive health services • Physical, occupational and speech therapy • Renal dialysis • Respiratory Services • Radiation and chemotherapy • Blood or blood products not provided free-ofcharge to the patient and the administration of these products • Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility. PKF-M100708R 12 • Requires authorization and physician prescription • 60 days per 12-month period limit • Requires prior authorization and physician prescription • No Co-pays for CHIP or CHIP Perinate Newborn Members • Applicable level of copay applies to prescription drug services for CHIP Members • Co-pays do not apply to preventive services for CHIP Members • No co-pays required for CHIP Perinate Newborn Members
Page 1 and 2: This book belongs to:______________
Page 3 and 4: WELCOME TO OUR PARKLAND KIDSfirst a
Page 5 and 6: ‣ We may provide information to a
Page 7 and 8: If you believe your privacy rights
Page 9 and 10: • What if I/my child has an emerg
Page 11 and 12: The Member ID is the same as your c
Page 13 and 14: How Do I Choose My Child's Primary
Page 15 and 16: You will get a letter in the mail i
Page 17 and 18: Parkland CHIP Perinate Newborn Memb
Page 19: • serious impairment to bodily fu
Page 23 and 24: Type of Benefit Description of Bene
Page 31 and 32: What benefits are not covered? Serv
Page 35 and 36: care is known as routine medical ca
Page 37 and 38: (How Do I Get Medical Care after My
Page 39 and 40: eferral is needed. Only one pair of
Page 41 and 42: You/ your daughter may contact any
Page 45 and 46: 5. Learn about what your health pla
Page 47 and 48: How will I be notified if services
Page 49 and 50: The Member Advocate will listen to

Member Handbook for Parkland KIDSfirst and Parkland CHIP ...

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