PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Appendix H RSV Illness 139
RATIONALE: Prevention of RSV Illness Based on American Academy of Pediatrics recommendations Respiratory Syncytial Virus (RSV) is the leading cause of infant hospitalizations and a leading viral cause of deaths in infants. The use of Palivizumab (Synagis®) for the prevention of RSV in certain infants has been shown to reduce hospitalizations and reduce morbidity and mortality in at risk infants. GOALS • To increase the numbers of at risk infants receiving Synagis prophylaxis • To increase the number of Synagis injections during the RSV season • To reduce hospitalizations in at risk infants due to RSV infection • To reduce morbidity and mortality in at risk infants due to RSV infection Background RSV season runs concurrently with flu season from November through April. A complete series of injections of Synagis® consists of one shot given monthly from October through March. NICU graduates and premature infants should typically be given the first shot before they are discharged from the hospital if it is during RSV season. Clinical Indications • Infants born at or below 32 weeks of gestation • Patients up to 2years of age who have chronic lung disease requiring supplemental oxygen, bronchodilator, diuretic or corticosteroid therapy within 6 months before the start of RSV season • Congenital abnormalities of the airways • Severe neuromuscular disease • Children 24 months and younger with hemodynamically significant cyanotic and acyanotic congenital heart disease. • Infants between 32-35 weeks gestation if two of the following risk factors exist: Child care attendance School-aged siblings Exposure to environmental air pollutants Protocol Prior to the start of RSV season and ongoing throughout the season: PCHP Data Analysts will identify members who may fit the Synagis® criteria. A letter will be sent to the PCP of record notifying the PCP that the member has been identified as a potential candidate for RSV prophylaxis. The letter will include a list of Synagis® providers within the PCHP network to whom the member may be referred. Members who have been identified by the PCP, but not meeting the listed criteria, will require prior authorization from the PCHP Medical Director for reimbursement to be made. Parents of identified members will receive a letter notifying them that their child may be a candidate for RSV prophylaxis and instructing them to contact the child’s PCP for evaluation. Authorization will extend from October through March and cover injections every 28-30 days, to include no more than six total injections in a single season. References H. Cody Meissner, Sarah S. Long the Committee on Infectious Diseases and Committee on Fetus and Newborn (1 Dec 2003) Revised Indications for the Use of Palivizumab and Respiratory Syncytial Virus Immune Globulin Intravenous for the Prevention of Respiratory Syncytial Virus Infections Pediatrics 112 (6): 1447-1452. Parkland Community Health Plan follows the guidelines of the American Academy of Pediatrics and the Centers for Disease Control and Prevention. This is not intended as a substitute for medical judgment. Each patient’s treatment plan should be individualized. (Developed June 2005) 140
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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
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Parkland Community Health Plan Memb
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Pregnant Teens Please call Parkland
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your income. Co-payments do not app
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Member’s Right to Designate an OB
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70 To report providers use this add
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5. Network providers must report an
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To request to be a Specialist servi
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• OB/Gyn • Periodic Health Chec
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The table below provides HHSC Manag
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CHIP Cost Sharing Caps Members rece
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of these two dates: July 18, 2007,
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(DD) Diagnosis code by specific ser
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(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 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: Follow-up • Follow-up urine cultu
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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