PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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• Have the Provider Relations Staff educate providers (doctors, nurses, social workers, and other providers) about WIC services and urge them to promote WIC services through appropriate education materials and outreach whenever appropriate. Special Needs of Member Populations Transportation PCHP is committed to minimizing this barrier by identifying members with transportation needs and coordinating services with other community based transportation program. Providers and their staff will be urged to help members identify and address their transportation needs. The availability of these services will be discussed during your Provider Orientation. Cultural Sensitivity It is critical that PCHP and its participating providers be sensitive to the vast cultural differences that span the PCHP population. To that end, it is critical that we, as partners, develop a culturally competent system of care – one that acknowledges and incorporates at all levels the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique needs. PCHP recipients will vary in language and culture (e.g., customs, religion, backgrounds, etc.). Our goal is to effectively serve members of all cultures, races, ethnic backgrounds and religions in a manner that recognizes, values, affirms, and respects the worth of the individuals and protects and preserves the dignity of each. We must operate at a level in which cultural knowledge is high, and policies and practices are in place that produce positive results and satisfaction from the viewpoint of the culturally diverse client. Adhering to the policies and procedures set by CHIP, any literature that is published for informational use by PCHP members needs to be written on a 6 th grade reading level. This will help to enhance the communication between the CHIP population, providers, and PCHP. Language/Interpreter Services PCHP offers language interpretation services to translate multiple languages. PCHP does this through The Language Line, which can be accessed by calling 1-888-814-2352. For persons that are deaf or hard of hearing, please call TTY line at 1-800-735-2989 and ask them to call the PCHP Member Services Line at 1-888-814- 2352. PCHP also maintains a current list of interpreters who remain available to provide interpreter services for providers. We will arrange, with 72-hour notice, to have someone that speaks the patient’s language meet the patient at the provider’s office when they come for their appointment. For members in need of a sign language interpreter, PCHP will provide an approved interpreter from the American Sign Language Association. Trained interpreters must be used when technical, medical, or treatment information is to be discussed, or where the use of a family member or friend is inappropriate. Family members, especially children, should not be used as interpreters in assessments, therapy and other situations where impartiality or confidentiality is critical unless specifically requested by the member. 111
As soon as the member knows they will need a language interpreter to meet them at the doctor’s office, the patient should contact Member Services at 1-888-814-2352. If a translator is needed on the weekend for any reason, the patient or doctor should contact Member Services. They will refer the member to an available translator. HMO/Provider Coordination PCHP will comply with the HHSC standards regarding care for persons with disabilities or chronic and complex conditions. PCHP will provide information, education and training programs to members, families, primary care providers, specialty physicians, and community agencies about the care and treatment available within Parkland Community Health Plan for members with disabilities or chronic or complex conditions. Specialists may function as a primary care provider for treatment of members with chronic/complex conditions when approved by PCHP. Federal and state laws prohibit unlawful discrimination in the treatment of patients on the basis of ethnicity, sex, age, religion, color, mental or physical disability, national origin, marital status, sexual orientation, or health status (including, but not limited to, chronic communicable diseases such as AIDS or HIV-positive status). All participating physicians and health care professionals may also have an obligation under the Federal Americans with Disabilities Act to provide physical access to their offices and reasonable accommodations for patients and employees with disabilities. For each person with disabilities or chronic or complex conditions, the Primary Care Provider is required to develop a plan of care that meets the special preventive, primary acute care and specialty care needs of the member. The plan must be based on: • 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 annually. PCHP will ensure the Members with Special Health Care Needs have adequate access to primary care providers and specialists skilled in treating persons with disabilities or chronic or complex conditions. Case Management services are available to assist members with special health care needs, their families, and health care providers to facilitate access to care, continuity and coordination of services. Confidentiality Reports, records and information furnished to a health authority or department that relates to cases or suspected cases of diseases or health conditions are confidential and can be used only for the purposes of this section. Reports, records, and information about cases or suspected cases of diseases or health conditions are not public information under Chapter 552, Government Code, and can not be released or made public on subpoena. Medical or epidemiological information can be released: 112
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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
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Expedited Appeal can be made verbal
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CHIP Eligibility CHIP KidsFirst Mem
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• 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 and 116: 1. History and Physical Examination
Page 117: WIC services include providing nutr
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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