PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Plan specified services. However, communication with the Primary Care Provider is urged to promote continuity of care. PCHP has an open provider network for all Parkland KidsFirst members. (Parkland KidsFirst does not limit the selection of a Primary Care Provider or referral to a specialist for KidsFirst members.) Parkland CHIP Perinate Newborn members will need to pick from providers indicated in the provider directory as participating in the Parkland CHIP Perinate Newborn. Additionally, Parkland CHIP Perinate member’s selection of a CHIP Perinatal provider is limited to only those providers listed within the Parkland CHIP Perinate Provider Directory. We Welcome You to Parkland KidsFirst, Parkland CHIP Perinate and Parkland CHIP Perinate Newborn! Parkland KIDSfirst, Parkland CHIP Perinate, and Parkland CHIP Perinate Newborn covered services/benefits are subject to change. Please refer to www.TMHP.com for updated information. 3
Provider Manual Overview Objectives of Program We have identified specific objectives to effectively manage and provide quality health care for the PCHP Members. The program objectives are to: ■Ensure network adequacy and timely access to care ■Provide timely claim payment ■Provide comprehensive behavioral health care ■Incorporate a cultural competency program to address the diverse cultural needs of our Members and ■Provide disease management programs appropriate for the populations we serve. Role of Primary Care Provider /Medical Home The Primary Care Provider (PCP) is the medical home for the Member. This provider delivers appropriate preventive and other primary care services within the scope of their practice and oversees the continuity and coordination of care among all health care practitioners involved in providing services to PCHP Members. Role of Specialty Care Provider The Specialty Care Provider can provide services after a referral has been made by the Member’s primary care provider. It is the responsibility of the specialist’s office to ensure that the Member has a valid referral from the primary care provider and authorization from PCHP Medical Management for services on the prior authorization list prior to rendering services. Members do not need primary care provider referrals for behavioral health, obstetrical/gynecological care, or other Plan specific services that are not on the prior authorization list. However, communication with the primary care provider is encouraged to promote continuity of care. Role of CHIP Perinate Provider A CHIP perinatal provider can be an obstetrician/gynecologist (OB/GYN), a family practice doctor or another qualified health care provider that provides prenatal care. Role of Pharmacy The pharmacy is a place where drugs are compounded or dispensed. The pharmacist is the dispenser of prescription drugs to Parkland Community Health Plan Medicaid and CHIP members when the physician prescribes a medication(s). Parkland Community Health Plan Medicaid contracts with Navitus to manage the pharmacy network. Network Limitations We have an open provider network for all Parkland KidsFirst Members. We do limit a Member’s selection of a primary care provider or a referral to a specialist to the Parkland KidsFirst network. 4
Page 1 and 2: Parkland KIDSfirst, Parkland CHIP P
Page 3 and 4: Notification of Change in Provider
Page 5 and 6: CLAIMS SUBMISSION .................
Page 8 and 9: Quick Reference Checklist This manu
Page 12 and 13: CHIP Covered Services PCHP provides
Page 14 and 15: • Surgical implants • Other art
Page 16 and 17: Outpatient Mental Health Services I
Page 18 and 19: • Out-of-network services not aut
Page 20 and 21: CHIP Perinatal Covered Services Cov
Page 22 and 23: 15 Covered Benefit CHIP Perinate Ne
Page 24 and 25: Covered Benefit CHIP Perinate Newbo
Page 30 and 31: • Personal comfort items includin
Page 32 and 33: • Donor non-medical expenses •
Page 34 and 35: SUPPLIES COVERED EXCLUDED COMMENTS/
Page 36 and 37: SUPPLIES COVERED EXCLUDED COMMENTS/
Page 38 and 39: Coordination between Physical and B
Page 40 and 41: in the provision of care and servic
Page 42 and 43: statement indicating that members s
Page 44 and 45: As the Primary Care Provider you mu
Page 46 and 47: Other Access Standards Service Stan
Page 48 and 49: Members Right to Select Network Oph
Page 50 and 51: HMO/Provider Coordination PCHP will
Page 52 and 53: 45 • describe the range of medica
Page 54 and 55: Coordination of Care The Primary Ca
Page 56 and 57: Coordination with Texas Department
Page 58 and 59: Presentation at Emergency Room afte
Page 60 and 61:
If the complaint is received verbal
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Expedited Appeal can be made verbal
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CHIP Eligibility CHIP KidsFirst Mem
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• Information concerning the grie
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Parkland Community Health Plan Memb
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Pregnant Teens Please call Parkland
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your income. Co-payments do not app
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Member’s Right to Designate an OB
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70 To report providers use this add
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5. Network providers must report an
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To request to be a Specialist servi
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• OB/Gyn • Periodic Health Chec
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The table below provides HHSC Manag
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CHIP Cost Sharing Caps Members rece
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of these two dates: July 18, 2007,
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(DD) Diagnosis code by specific ser
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(PP) Attending physician ID (UB-04,
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(2) post-partum visits within 60 da
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CHIP Member Enrollment and Disenrol
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• In order to synchronize all CHI
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Provider Participation Requirements
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• Evidence of state licensure, an
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U1 U2 U3 Medically necessary delive
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PROCEDURE DESCRIPTION PROCEDURE COD
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provider actually treating the memb
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themselves appropriately and follow
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Medical Record Standards The medica
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1. History and Physical Examination
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WIC services include providing nutr
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As soon as the member knows they wi
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3) by the director to the employee
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In addition to the previously state
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Prior Authorization The CHIP Perina
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Appendix A Universal Referral/Prior
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Appendix B Consent for Disclosure 1
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PERMISSION TO RELEASE CONFIDENTIAL
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EXAMPLE FORM PRIVATE PAY AGREEMENT
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Appendix D Clinical Practice Guidel
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Appendix D - Continued Clinical Pra
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Appendix D - Continued Clinical Pra
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RATIONALE: Attention-Deficit/ Hyper
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Appendix G Urinary Tract Infections
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Follow-up • Follow-up urine cultu
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RATIONALE: Prevention of RSV Illnes
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RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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