PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

More documents

Recommendations

Info

identification. Members who properly identify themselves will be allowed to see their health care information. • Members who wish a copy of their health care information can do so at no charge to the member. Monitoring Compliance • The PCHP provider network will be evaluated periodically to decide whether there are enough STD/HIV providers disbursed geographically throughout the service area to ensure that members who require STD/HIV services are able to access them easily. • Compliance with PCHP policies and procedures regarding STD/HIV provider education will be measured through a periodic, retrospective review of the number and effectiveness of the STD/HIV courses and education materials. • Compliance with PCHP policies and procedures regarding STD/HIV service delivery, confidentiality and reporting will be measured through periodic medical record reviews conducted by the Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn QI Department. • Compliance with the requirement that STD/HIV services be managed in accordance with a protocol approved by the Commissioner of Health will be measured through a review of the procedures, protocols, guides, and standards that providers use to provide STD/HIV services and treatment. • Compliance will also be measured through periodic record reviews conducted by Medical Management with a sample of providers. • Reports of compliance with the subject policies and procedures will be submitted on a yearly basis to the Clinical Quality Improvement Committee and to Provider Relations for evaluation. • Providers found to be out of compliance will be required to develop and implement a corrective action plan as a condition of recredentialing. • PCHP’s STD/HIV policies and procedures will be evaluated periodically by Medical Management and Provider and Community Relations to find out their effectiveness. Policies and procedures that are found to be ineffective and inconsistent or a barrier to easily accessible and effective STD/HIV services will be amended accordingly. Health Departments PCHP has established agreements with county and local health departments for members to be able to access the full range of services these entities provide. A list of services available by location and entity will be provided as part of your orientation. Women, Infants and Children Program (WIC) The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a health and nutritional program with a successful record of improving the diets of infants, children, and pregnant, postpartum and breastfeeding women who are at risk for nutrition-related illness. The main focus of the WIC program is to educate mothers on the proper nutrition for babies and young children. 109
WIC services include providing nutritional supplementation for pregnant women and children under age 5, as well as nutritional education and counseling services. PCHP’s network is located with maternity, Family Planning and WIC services at all of its Community Oriented Primary Care (COPC) clinics. This enables members to have one-stop access to a number of services which can meet many maternal and child health needs of members. COPC providers which include doctors, nurse practitioners, doctor assistants, Social workers, nutritionists, among others, help members with registering for and obtaining WIC services, which can be accessed within the same facility. To learn more and to find a local WIC office near you, call 214-670-7200. It is essential for the Texas Health Steps staff to educate members and providers alike on the importance of the WIC program in order to ensure that both parties are aware of the positive impact that effective nutritional supplementation can have on health outcomes for women, infants, and children. This includes making providers and members aware of: 110 • The type and nature of WIC services available; • The importance of WIC in maintaining maternal and child health; • Eligibility requirements for obtaining WIC services; • The referral process and tracking system; • WIC providers located at COPC clinics that offer multiple services at one location convenient to the member’s neighborhood; • Other WIC providers who are geographically more accessible to members; • Material given to members about the WIC program; • Basic PCHP managed care guidelines for providers offering WIC services; and, • Members and providers are also made aware of the WIC program and the service it provides through the: Member Orientation Provider Orientation Member Handbook Provider Manual WIC provider brochure. To effectively meet the needs of women, infants, and children, PCHP will: • Ensure that PCHP members and providers make available WIC specific medical information to WIC programs including: height, weight, hematocrit, hemoglobin, and other risk conditions. • Ensure that all eligible PCHP members not already participating in WIC are referred to the WIC program. • Emphasize to providers the important role that WIC plays in community health and actively urge them to fully participate with PCHP initiatives. • Coordinate effective member and provider education through the PCHP Community Outreach Department. • Screen members for WIC participation through the Community Outreach Department activities. • Advise PCHP providers to refer every newly pregnant member to WIC at the first prenatal contact and to check on WIC status during prenatal visits and at the time of delivery. Providers will be trained on the provision of WIC services during their initial training process, and also receive information in the Provider Manual.
Page 1 and 2:
Parkland KIDSfirst, Parkland CHIP P
Page 3 and 4:
Notification of Change in Provider
Page 5 and 6:
CLAIMS SUBMISSION .................
Page 8 and 9:
Quick Reference Checklist This manu
Page 10 and 11:
Plan specified services. However, c
Page 12 and 13:
CHIP Covered Services PCHP provides
Page 14 and 15:
• Surgical implants • Other art
Page 16 and 17:
Outpatient Mental Health Services I
Page 18 and 19:
• Out-of-network services not aut
Page 20 and 21:
CHIP Perinatal Covered Services Cov
Page 22 and 23:
15 Covered Benefit CHIP Perinate Ne
Page 24 and 25:
Covered Benefit CHIP Perinate Newbo
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
• Personal comfort items includin
Page 32 and 33:
• Donor non-medical expenses •
Page 34 and 35:
SUPPLIES COVERED EXCLUDED COMMENTS/
Page 36 and 37:
SUPPLIES COVERED EXCLUDED COMMENTS/
Page 38 and 39:
Coordination between Physical and B
Page 40 and 41:
in the provision of care and servic
Page 42 and 43:
statement indicating that members s
Page 44 and 45:
As the Primary Care Provider you mu
Page 46 and 47:
Other Access Standards Service Stan
Page 48 and 49:
Members Right to Select Network Oph
Page 50 and 51:
HMO/Provider Coordination PCHP will
Page 52 and 53:
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 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 and 112: themselves appropriately and follow
Page 113 and 114: Medical Record Standards The medica
Page 115: 1. History and Physical Examination
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
show all

PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?