PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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The practitioner will be notified immediately of any problems regarding an incomplete credentialing application or difficulty collecting requested information or of any information obtained by PCHP during the credentialing process that varies substantially from the information given to PCHP. In the event that credentialing information obtained from other sources varies substantially from that given by the practitioner, the Medical Director will be informed of the variance. The Medical Director will send the practitioner a certified letter requesting that the practitioner provide the Medical Director with additional written information with respect to the identified discrepancy within five (5) working days from receipt of the letter. PCHP will allow the practitioner to correct erroneous information collected during the credentialing process. PCHP primary care providers are required to have a site visit to the provider offices as part of the initial credentialing process. If physicians or providers are part of a group practice, which shares the same office, one visit to the site can be used for all physicians and providers in that office as long as medical records for each physician or provider are sampled. Site visits shall consist of an evaluation of the site’s accessibility, appearance, space, and the adequacy of equipment, using standards developed by PCHP. In addition, the site visit shall include a review of medical record keeping practices and confidentiality requirements. Recredentialing Recredentialing procedures for the physicians and individual providers shall include, but are not limited to the following sources: • Licensure • Clinical Privileges • Board Certification (only if the doctor was due to be recertified or states that he/she has become board certified since the last time he/she was credentialed) • Sanctions/restrictions – We will query the National Practitioner Data Bank and obtain updated sanction or restriction information from licensing agencies and Medicare. • Site visits will be conducted for Primary Care Providers and high volume doctors and providers. Multipractitioner sites should be visited every three years. Medical record audits, including evaluation of the quality of encounter notes, shall be performed within three (3) years before recredentialing. The practitioner will be notified immediately of any problems regarding an incomplete credentialing application, difficulty collecting requested information, or of any information obtained by PCHP during the credentialing process that varies substantially from the information given to PCHP. In the event that credentialing information obtained from other sources varies substantially from that given by the practitioner, the Medical Director will be informed of the variance. The Medical Director will send the practitioner a certified letter requesting that the practitioner provide the Medical Director with additional written information with respect to the identified discrepancy within 5 working days from receipt of the letter. PCHP will allow the practitioner to correct erroneous information collected during the credentialing process. Organizational Providers Credentialing and recredentialing process for institutional providers shall include, but not be limited to the following: 95
• Evidence of state licensure, and of compliance with any other applicable state and federal requirements; • Evidence of approval by a recognized accrediting body. If the provider is not accredited, PCHP will evaluate the provider against established standards. PCHP shall recredential institutional providers at least every three years. Referrals Referrals to other participating providers, other than the member’s Primary Care Provider, require completion of a referral form by the Primary Care Provider. The provider and participating specialist are expected to communicate regarding the health care services given to each member. In-Network Referrals The Parkland KIDSfirst, or Parkland CHIP Perinate Newborn member’s Primary Care Provider is responsible for and will coordinate referrals of the member to other providers, in- and out-of-network. The steps for an innetwork referral are listed below: • A member presents for care and requires referral for services; • The Parkland KIDSfirst, or Parkland CHIP Perinate Newborn member’s Primary Care Provider completes a referral form. The in-plan referral is valid for thirty (30) days for a maximum of two visits unless otherwise authorized by the Primary Care Provider. A new referral request must be completed if the referral is over thirty (30) days old or if more than two visits are required. Direct Access Services Parkland KIDSfirst and Parkland CHIP Perinate Newborn members can seek the following services without a referral from a Primary Care Provider: • OB/GYN • Value-Added services • Well Child Services • Behavioral Health Referrals to Ancillary Services All providers can refer members for routine laboratory and radiology services to a PCHP participating provider using the standard PCHP referral form. However, some procedures require prior authorization. Please see the Prior Authorization section for a comprehensive listing of these procedures. PCHP providers are required to send routine lab and radiology requests to one of the lab/radiology providers listed in the Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn Provider Directory. If a required radiological service is not available within the Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn network, the member’s Primary Care Provider or CHIP Perinatal provider must complete a prior authorization using the Texas Referral/Authorization Form and follow the standard out-of-network referral procedures outlined above. 96
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
Page 8 and 9:
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
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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 and 100: • In order to synchronize all CHI
Page 101: Provider Participation Requirements
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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