PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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- Health needs - Specialist recommendations - Periodic reassessment of the member’s functional status and service delivery needs. • The Primary Care Provider must maintain an initial plan of care in the medical records of persons with disabilities or chronic or complex conditions and that plan must be updated as often as the member’s needs change, but at least yearly. • PCHP will ensure the provider networks have adequate capacity of Primary Care Providers and specialists skilled in treating persons with disabilities or chronic or complex conditions. Note the following requirements: - Specialty doctors must be board Certified/Eligible; - Texas licensed doctors can offer specialty care within PCHP under the direction of the PCHP Medical Director; - PCHP is required to verify documented experience of Primary Care Providers and Specialty Care Providers to ensure they have experience in treating persons with disabilities or chronic or complex conditions; and, - For children with disabilities or chronic and complex conditions, PCHP is required to obtain proof of demonstrated Primary Care Provider or Specialty care experience in treating members of this kind at children’s hospitals, medical schools, or teaching hospitals. • PCHP makes every effort to establish relationships with community organizations in order to make referrals for CHIP members with chronic or complex conditions. These organizations can include: - Early Childhood Intervention (ECI) - Department of Mental Health and Mental Retardation (MHMR) - Texas Department of State Health Services (DSHS) Title V Program - Local School District (Special Education) - Other state and local agencies and program with jurisdiction over children’s services, including food stamps, Women, Infants, and Children’s (WIC) Program - Texas Information and Referral Network - Texas Department of Assistive and Rehabilitative Services (DARS) - Child-serving civic and religious organizations and consumer and advocacy groups, such as United Cerebral Palsy, that also work on behalf of the chronic and complex population. Home Health PCHP provides for home health care services when ordered by the doctor and approved by PCHP. Home Health services are not a benefit for Parkland CHIP Perinate members. Home health care services can include nursing care, intravenous medication, respiratory therapy, physical therapy, speech therapy, home health aid services, etc. and require prior authorization. Durable Medical Equipment Services also require prior authorization as detailed in the Prior authorization section. A copy of the Prior Authorization form is provided in Appendix A of this manual. 105
Medical Record Standards The medical records reflect all aspects of patient care, including ancillary services. These standards shall, at a minimum, include requirements for: 1) Patient identification information. Each page or electronic file in the record contains the patient's name or patient ID number. 2) The use of electronic medical records must conform to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) and other federal and state laws. 3) Personal/biographical data, including: age; sex; address; employer; home and work phone numbers; and marital status. 4) All entries are dated and author identified. 5) The record is legible to someone other than the writer. A second reviewer should evaluate any record judged illegible by one physician reviewer. 6) Allergies. Medication allergies and adverse reactions are prominently noted on the record. Absence of allergies (no known allergies – NKA) is noted in an easily recognizable location. 7) Past Medical History (for patients seen three or more times). Past medical history is easily identified including serious accidents, operations, and illnesses. For children, past medical history relates to prenatal care and birth. 8) Immunizations. For pediatric records there is a completed immunization record or a notation of prior immunizations, including vaccines and dates given, when possible. 9) Diagnostic Information. 10) Medication Information (includes medication information/instruction to member). 11) Identification of Current Problems. Significant illnesses, medical and behavioral health conditions, and health maintenance concerns are identified in the medical record. 12) Member is provided basic teaching/instructions regarding physical and/or behavioral health condition. 13) Smoking/Alcohol/Substance Abuse. Notation concerning cigarettes and alcohol use and substance abuse is present. Abbreviations and symbols may be appropriate. 14) Consultations, Referrals and Specialist Reports. Notes from any referrals and consultations are in the record. Consultation, lab, and X-ray reports filed in the chart have the ordering doctor's initials or other documentation signifying review. Consultation and any abnormal lab and imaging study results have an explicit notation in the record of follow-up plans. Referrals to out-of-network providers (non-contracted providers) must include justification to Parkland KIDSfirst or Parkland CHIP Perinate Newborn. (See Out-of- 106 Network Referrals on page 81) 15) All emergency care provided (directly by the contracted provider or through an emergency room) and the hospital discharge summaries for all hospital admissions while the patient is enrolled. 16) Hospital Discharge Summaries. Discharge summaries are included as part of the medical record for: (1) all hospital admissions, which occur while the patient is enrolled with the Contractor, and two (2) prior admissions as necessary. Prior admissions as necessary pertain to admissions, which may have occurred before member being enrolled with the Contractor, and are pertinent to the member’s current medical
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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
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Presentation at Emergency Room afte
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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 and 108: PROCEDURE DESCRIPTION PROCEDURE COD
Page 109 and 110: provider actually treating the memb
Page 111: themselves appropriately and follow
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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