PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Provider Manual Overview
Objectives of Program
We have identified specific objectives to effectively manage and provide quality health care for the PCHP
Members. The program objectives are to:
■Ensure network adequacy and timely access to care
■Provide timely claim payment
■Provide comprehensive behavioral health care
■Incorporate a cultural competency program to address the diverse cultural needs of our Members and
■Provide disease management programs appropriate for the populations we serve.
Role of Primary Care Provider /Medical Home
The Primary Care Provider (PCP) is the medical home for the Member. This provider delivers appropriate
preventive and other primary care services within the scope of their practice and oversees the continuity and
coordination of care among all health care practitioners involved in providing services to PCHP Members.
Role of Specialty Care Provider
The Specialty Care Provider can provide services after a referral has been made by the Member’s primary care
provider. It is the responsibility of the specialist’s office to ensure that the Member has a valid referral from the
primary care provider and authorization from PCHP Medical Management for services on the prior
authorization list prior to rendering services. Members do not need primary care provider referrals for
behavioral health, obstetrical/gynecological care, or other Plan specific services that are not on the prior
authorization list. However, communication with the primary care provider is encouraged to promote continuity
of care.
Role of CHIP Perinate Provider
A CHIP perinatal provider can be an obstetrician/gynecologist (OB/GYN), a family practice doctor or another
qualified health care provider that provides prenatal care.
Role of Pharmacy
The pharmacy is a place where drugs are compounded or dispensed. The pharmacist is the dispenser of
prescription drugs to Parkland Community Health Plan Medicaid and CHIP members when the physician
prescribes a medication(s). Parkland Community Health Plan Medicaid contracts with Navitus to manage the
pharmacy network.
Network Limitations
We have an open provider network for all Parkland KidsFirst Members. We do limit a Member’s selection of a
primary care provider or a referral to a specialist to the Parkland KidsFirst network.
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