PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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PROCEDURE DESCRIPTION PROCEDURE CODES Gastroplasty/gastric bypass 43631, 43632, 43633, 43634, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 49999 Uvulopalatopharyngoplasty (UP3 or LAUP) 42145, 42140, 42299 Circumcision in children over 1 year of age 54152, 54161 Abortion 59840-59857, 59866 Durable Medical Equipment, Supplies, Prosthetics, Orthotics All requests where the total amount of the request is greater than $1,000 (including but not limited to): Hospital Beds Electric Scooter Customized Braces/Orthotics Upper Limb Prosthetics Lower Limb Prosthetics Wheelchairs Cranial Molding Helmets The information provided and the recommendation of the patient’s doctor or provider will be used to make prior authorization determinations. Services will be approved as proposed or referred to a Medical Management Medical Director in the event there are questions about the clinical aspects for the recommended services, including appropriateness of level of care. Medical Management (MM) makes decisions based on the appropriateness of care and service. Requests for coverage are reviewed to decide if the service requested is a covered benefit and is delivered in accordance with established guidelines. If a request for coverage is denied, the member (or a doctor acting on behalf of the member) can appeal this decision through the complaint and appeal process. Medical Management has adopted screening criteria and established review procedures which are periodically evaluated and updated with appropriate involvement from doctors, including practicing doctors and other health care providers. Utilization Review decisions are made in accordance with currently accepted medical or health care practices, taking into account special circumstances of each case. Milliman Care Guidelines®, the screening criteria, are nationally recognized objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from the norms when justified on a case-by-case basis. In addition, the Medical Management staff uses Clinical Policy Bulletins (CPBs) as supplemental guidelines in determining the safety, effectiveness and medical necessity of selected medical technologies. Screening criteria is used to decide only whether to approve the requested service. Flexibility can be used when applying screening criteria in determining utilization review decisions for members with special health care needs. This can involve members who have a disability, acute condition or a life-threatening illness. Cases that cannot be approved by a nurse reviewer are referred to a Medical Director to decide on medical necessity. In any instance where a service authorization request or authorization of service in an amount, duration or scope less than that requested is questioned, the health care provider who ordered the services shall be afforded a reasonable chance to discuss the plan of treatment for the patient with the clinical basis for the decision with a doctor before the issuance of a determination. At least two documented attempts at consultation between the Medical Director and the treating doctor will be made before an adverse determination. Prior authorization is not required for emergency services and does not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. The attending emergency doctor or the 101
provider actually treating the member is responsible for determining when the member is stable. However, admissions for observation or inpatient services for post-stabilization care are subject to prior authorization and notice requirements. Medical Management must be notified within two (2) business days of the admission. Post-stabilization care provided to maintain, improve or resolve the member’s stabilized condition is covered for the period of time it takes for Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn to make a determination, including times the Plan cannot be contacted, does not respond to a request for approval, or a Medical Director is not available for consultation when medical necessity is questioned by the Medical Management staff. Transplants Members that require organ/tissue transplants that include bone marrow, peripheral stem cell, heart, lung, liver, kidney and combined heart/lung receive case management services to facilitate continuity and coordination of care among the providers who care for the member. Transplants must be performed in an institution that is certified by Texas Medicaid and participates in the PCHP network. Prior authorization for transplant services is required and exceptions to any provisions defined in the Texas Medicaid Provider Procedures Manual must be approved by the Medical Director. To request Case Management services for a member who is a potential transplant recipient, call the Medical Management department. Physician Obligations for Hospital Admissions The following steps should be followed when admitting a patient to the hospital: Emergency Care: • The patient is admitted. • The patient receives care. • The provider verifies eligibility; • The admitting provider must notify PCHP’s Utilization Management Department by faxing a Hospital prior authorization form to 1-800-240-0410 within one (1) business day. • The prior authorization form is reviewed by a MM nurse and an admission is entered into the system; • The MM nurse performs a concurrent/retrospective review based on the information supplied by the provider. • If the patient meets criteria, the nurse will approve the stay on a day-to-day basis. • If the patient does not meet criteria, the admitting provider will be notified that the admission is in question and will be referred to the Medical Director for review and disposition. Elective Admissions • A member presents for care and requires hospitalization (e.g., surgical procedure); • The admitting doctor completes the Texas Referral/Authorization form and faxes it to PCHP’s Medical Management Department at 1-800-240-0410 for approval. For elective admissions, the prior authorization form must be received within 2 business days of the scheduled admission provided all necessary information is complete; • The prior authorization form is reviewed by a Medical Management nurse and either approved or forwarded to the Medical Director for review. If the prior authorization is denied, a reason will be given to the requesting provider; • The Medical Management staff will enter the prior authorization into the system and sends the authorization number to the provider to include on the claim when submitted for reimbursement. If the determination results in denial, the provider will receive written notification and includes instructions on how to submit an appeal. 102
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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
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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 and 106: U1 U2 U3 Medically necessary delive
Page 107: PROCEDURE DESCRIPTION PROCEDURE COD
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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