PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Patient Education Procedures • Providers can inform their patients regarding the plans in which they participate. • Providers can inform their patients of the benefits, services, and specialty care providers offer through the CHIP plans in which they participate. • At the patients’ request, providers can give patients the information necessary to contact a particular health plan. • Providers can distribute or display written health educational materials or health related posters (no larger than 16 x 24) provided it is done for all plans in which the providers participate; these materials can have the health plan’s name, logo, and phone number. • Providers can display plan stickers indicating they participate with a particular Health Plan as long as they do not indicate anything more than “health plan is accepted or welcomed here.” In the case of CHIPspecific materials, stickers must feature the HHSC CHIP logo. Frequently Asked Questions about the Marketing Guidelines 1. In discussing CHIP with my patients, can I say “If you want to keep seeing me as your doctor, you must pick [names of all plans in which you participate] as your health plan(s) when you are completing the enrollment form”? Answer: Yes. To reiterate the intent of the policy; however, a provider who participates in more than one CHIP health plan must mention each plan and this must happen in a way that does not cast one plan in a more favorable light than the others. 2. If I am enrolled in more than one CHIP health plan network, do I have any responsibilities in mentioning both of them to my patients? Answer: If you participate in more than one CHIP health plan, and you are discussing CHIP with a patient, you must mention your participation in each of the plans or not mention them at all. You can not indirectly promote one plan by failing to refer to the other one. 3. Can someone in my office help a family complete the CHIP application? Answer: Yes. 4. Can someone in my office help a family complete the CHIP health plan selection form? Answer: No. Texas Department of Insurance standards do not permit providers to become directly involved in the health plan selection or enrollment process. Enrollment will be conducted centrally by CHIP. 5. Can I distribute to my patients free items that display health plan information? Answer: No. Providers can not give out or display health plan marketing materials or items, including giveaways. 93
Provider Participation Requirements Credentialing of Physicians and Licensed Independent Practitioners Credentialing shall be required for physicians and licensed independent practitioners. Credentialing is not required for providers who furnish services under the direct supervision of a physician or provider or hospitalbased physicians or providers who only provide services incidental to hospital services. Initial credentialing process for physicians and individual providers shall include, but not to be limited to, the following: • The applicant shall complete an application for affiliation. The application shall include a work history covering at least five years and a statement by the applicant regarding any limitations in ability to perform the functions of the position, history of loss of license and /or felony convictions, and history of loss or limitation of privileges or disciplinary activity. The application shall also include whether the physician will accept new patients from Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn. The following shall be verified from primary sources and included in the credentialing file: • A current valid license to practice in the State of Texas. The primary source for verification shall be the appropriate Texas State licensing agency or board. • If applicable, clinical privileges in good standing at the hospital designated by the physician or dentist as the primary network admitting facility. • If not Board Certified, education and training, including evidence of graduation from the appropriate professional school and completion of a residency or specialty training, if applicable. Primary source verification shall be sought from the appropriate schools and training facilities. If the state licensing board or agency verifies education and training with the physician or provider’s schools and facilities, evidence of current State licensure shall also serve as primary source verification of education and training. • If the physician states that he/she is board certified on the application, primary source verification can be obtained from the American Board of Medical Specialties, the American Osteopathic Association, the American Medical Association Master File, or from the specialty boards. The following will also be included in the physician or individual provider’s credentialing file: • Malpractice history from the National Practitioner Data Bank; • Information on previous sanction activity by HHSC or CHIP; • Copy of a valid Drug Enforcement Agency (DEA) and Department of Public Safety Controlled Substance permit, if applicable; • Evidence of current, adequate malpractice insurance meeting the HMO’s requirements; and, • Information about sanctions or limitations on licensure from the applicable state licensing agency or board; • Professional liability claims history. 94
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
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Quick Reference Checklist This manu
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Plan specified services. However, c
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CHIP Covered Services PCHP provides
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• Surgical implants • Other art
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Outpatient Mental Health Services I
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• Out-of-network services not aut
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CHIP Perinatal Covered Services Cov
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15 Covered Benefit CHIP Perinate Ne
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Covered Benefit CHIP Perinate Newbo
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• Personal comfort items includin
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• Donor non-medical expenses •
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SUPPLIES COVERED EXCLUDED COMMENTS/
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SUPPLIES COVERED EXCLUDED COMMENTS/
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Coordination between Physical and B
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in the provision of care and servic
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statement indicating that members s
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As the Primary Care Provider you mu
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Other Access Standards Service Stan
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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
Page 62 and 63: Expedited Appeal can be made verbal
Page 64 and 65: CHIP Eligibility CHIP KidsFirst Mem
Page 66 and 67: • Information concerning the grie
Page 69 and 70: Parkland Community Health Plan Memb
Page 71 and 72: Pregnant Teens Please call Parkland
Page 73 and 74: your income. Co-payments do not app
Page 75 and 76: Member’s Right to Designate an OB
Page 77 and 78: 70 To report providers use this add
Page 79 and 80: 5. Network providers must report an
Page 81 and 82: To request to be a Specialist servi
Page 83 and 84: • OB/Gyn • Periodic Health Chec
Page 85 and 86: The table below provides HHSC Manag
Page 87 and 88: CHIP Cost Sharing Caps Members rece
Page 89 and 90: of these two dates: July 18, 2007,
Page 91 and 92: (DD) Diagnosis code by specific ser
Page 93 and 94: (PP) Attending physician ID (UB-04,
Page 95 and 96: (2) post-partum visits within 60 da
Page 97 and 98: CHIP Member Enrollment and Disenrol
Page 99: • In order to synchronize all CHI
Page 103 and 104: • Evidence of state licensure, an
Page 105 and 106: U1 U2 U3 Medically necessary delive
Page 107 and 108: PROCEDURE DESCRIPTION PROCEDURE COD
Page 109 and 110: provider actually treating the memb
Page 111 and 112: themselves appropriately and follow
Page 113 and 114: Medical Record Standards The medica
Page 115 and 116: 1. History and Physical Examination
Page 117 and 118: WIC services include providing nutr
Page 119 and 120: As soon as the member knows they wi
Page 121 and 122: 3) by the director to the employee
Page 123 and 124: In addition to the previously state
Page 125 and 126: Prior Authorization The CHIP Perina
Page 127 and 128: Appendix A Universal Referral/Prior
Page 129 and 130: Appendix B Consent for Disclosure 1
Page 131 and 132: PERMISSION TO RELEASE CONFIDENTIAL
Page 133 and 134: EXAMPLE FORM PRIVATE PAY AGREEMENT
Page 135 and 136: Appendix D Clinical Practice Guidel
Page 137 and 138: Appendix D - Continued Clinical Pra
Page 139 and 140: Appendix D - Continued Clinical Pra
Page 141 and 142: RATIONALE: Attention-Deficit/ Hyper
Page 143 and 144: Appendix G Urinary Tract Infections
Page 145 and 146: Follow-up • Follow-up urine cultu
Page 147 and 148: RATIONALE: Prevention of RSV Illnes
Page 149 and 150: RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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