PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Prior Authorization Prior authorization is the utilization review processes to decide whether the requested service, procedure, medication or medical device meets clinical criteria for coverage. Prior authorization is not a guarantee of payment for care or services given to members. The prior authorization process requires the collection of information before inpatient admissions, performance of ambulatory procedures or delivery of selected services in order to: • Permit verification of eligibility and benefits • Provide a chance for communication with the doctor and/or the member • Coordinate the patient’s transition across the continuum of care • Help in the identification of members eligible for special programs A Primary Care Provider must complete the Texas Referral/ Authorization Form for all services on the <strong>Parkland</strong> Prior Authorization list except for the following: • Submit all DME requests on the Title XIX form • Submit all initial outpatient therapy requests utilizing the TP1 form • Submit TP1 (request for initial outpatient therapy) or TP2 (request for extension of outpatient therapy). The completed form (Appendix D) should be faxed to the Medical Management Department at the number listed in the Important Numbers (see page 1 of this manual). Notification regarding newborn and sonogram process The authorization process for newborn delivery/admission and sonograms is as follows: Newborn admission/delivery B process: • Authorization must be requested for any newborn after day 4 of stay • DRG hospitals must meet the acute LOC level of care • A prepayment review will be conducted on all DRG 790's • All others will be paid - with random audits conducted periodically. Sonogram process: • CHIP Perinate -– Members can get one sonogram per pregnancy. For additional procedures, there must be a high- risk diagnosis along with supporting clinical documentation. Information must be submitted and approved prior to the 2nd sonogram being performed. Complete the Texas Referral Authorization Form and fax to 1-800-240-0410. OB process: • No authorization is required for OB global days (2-day uncomplicated delivery & 4-day uncomplicated C-section). • Anything outside of the OB global must be authorized. • If the DRG is a higher DRG upon submission of claim, must follow the current appeal process for any denied claims. Contact your provider relations representative or call 1-888-672-2277 with questions about these changes. Claims for Obstetric Deliveries to Require a Modifier Claims that are submitted for obstetric delivery procedure codes 59409, 59410, 59514, 59515, 59612, 59614, 59620, or 59622 will require one of the following modifiers: 97 Modifier To Indicate
U1 U2 U3 Medically necessary delivery prior to 39 weeks of gestation Delivery at 39 weeks of gestation or later Non-medically necessary delivery prior to 39 weeks of gestation Note: Claims for deliveries that are submitted without one of the required modifiers will be denied. Texas Medicaid will restrict any Cesarean section, labor induction, or any delivery following labor induction to one of the following additional criteria: • Gestational age of the fetus should be determined to be at least 39 weeks or fetal lung maturity must be established before delivery. • When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery. Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to 39 weeks of gestation and are not considered medically necessary will be denied. Records will be subject to retrospective review. Payments made for non-medically-indicated Cesarean section, labor induction, or any delivery following labor induction that fail to meet these criteria (as determined by review of medical documentation), will be subject to recoupment. Recoupment may apply to all services related to the delivery, including additional physician fees and the hospital fees. 98
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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
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HMO/Provider Coordination PCHP will
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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 and 102: Provider Participation Requirements
Page 103: • Evidence of state licensure, an
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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