PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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PCHP CHIP/CHIP Perinatal Prior-Authorization List for Participating Providers Effective May 2011 PROCEDURE DESCRIPTION Inpatient Hospitalizations/inpatient admissions • All elective admissions to a facility including acute, skilled, hospice, rehabilitation and partial hospitalization for any medical, surgical, obstetrical, or behavioral health condition. • All inpatient facility to facility transfers – The transferring facility is responsible for obtaining prior authorization prior to the transfer to the new facility • All non-elective admission notification is required. Please submit clinical information for medical necessity for admission and level of care within two business days of the admission date. In-office Specialty Care Referrals Any non-urgent referral for out of network specialists office visits, regardless of specialty Any Provider other than the member’s Primary Care Provider of record on the date of service All Dermatology services Podiatry (except for services related to diabetic foot care – Diabetes must be primary diagnoses) PROCEDURE CODES 10040 - 19499 Surgery Skin 30620 Septal/intranasal dermatoplasty 36400 - 36550 Surgery (Venous) 85007 - 85048 hematology and coagulation 99201 - 99215 Office and other outpatient service 99241 - 99245 Office and other outpatient consultations All Related Codes Except for services related to diabetes 250.x All Neuropsych evaluations 96101, 96118 Obstetrical and Perinatology - Notification required after the first visit to ensure member is screened for OB case management Diagnostic Testing Genetic testing for those over the age of 1 year Ultrasound OB Ultrasound (applies to CHIP Perinate only 76801-76828 Ambulance Non-emergent Ambulance Transportation – Air or Ground Home <strong>Health</strong> Care Skilled Nursing Rehabilitation/Physical, Occupational, Speech therapy Private Duty Nursing Infusion Therapy Home <strong>Health</strong> Aide/ Personal Care Assistant Medical Injectables – In office or home 99 83890 - 84999 Pathology and Lab/Chemistry 86805 - 86849 Tissue Typing 88230 - 88299 Cytogenic Studies 99201 - 99215 Office and other outpatient services 99241 - 99245 Office and other outpatient consultations S3820, S3822, S3823 Brach Genetic Testing
PROCEDURE DESCRIPTION PROCEDURE CODES Growth Hormone J2170, J2940, J2941, Q0515, S9558, 83003, IVIG J1561, J1562, J1566, J1567, J1568, J1569, J1572 90281, 90283, 90284, 90399 Synagis® not obtained from the Vendor Drug Program C9003; J1565; S9562, 90378; 90379; Remicade 17 Alpha Hydrozyprogesterone Caproate (17P) Pain management – intrathecal, epidural, trigger point injections, facet injections, joint injections, etc. Intrathecal Baclofen Pump Xolair Transplants All transplant work-ups and procedures Outpatient Rehabilitation/Habilitatation/Therapies – excluding initial evaluation Physical Therapy Occupational Therapy Speech Therapy Respiratory Therapy Outpatient Procedures Removal of premalignant, malignant lesions 11600-11646 Dental/Oral Maxillofacial/Craniofacial General dental anesthesia Orthognathic surgery procedures/osteotomies 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21159, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215 D codes: D7940,D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996 TMJ Cosmetic Procedures (including but not limited to): Reconstructive repairs, injection of filling material (including collagen) 100 11950, 11951, 11952, 11954 Excision of skin 15831-15839 Removal of Benign lesion 11400-11446 Otoplasty 69300, 69399 Breast Reconstruction 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, S2066, S2067, S2068 Reconstructive repair of pectus excavatum or carinatum 21740, 21742, 21743 Reduction Mammoplasty/Gynecomastia 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342 Lipectomy 15876, 15877, 15878, 15879 Venous Ligation 36475, 36476, 36478, 36479, 37204, 37700, 37718, 37722, 37735, 37760, 37765, 37766, 37780, 37785, 75894 Sclerotherapy 36468, 36469, 36470, 36471 Rhinoplasty 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30620 Blepharoplasty 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67916, 67917, 67923, 67924, 67950 Canthopexy 21282 Canthoplasty 67950 Cervicoplasty 15819 Rhytidectomy 15824, 15825, 15826,15828, 15829
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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
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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 and 104: • Evidence of state licensure, an
Page 105: U1 U2 U3 Medically necessary delive
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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