PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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• Out-of-network services not authorized by the Health Plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section • Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan • Acupuncture services, naturopathy and hypnotherapy • Immunizations solely for foreign travel • Routine foot care such as hygienic care • Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) • Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor • Corrective orthopedic shoes • Convenience items • Orthotics primarily used for athletic or recreational purposes • Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice services. • Housekeeping • Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities • Services or supplies received from a nurse, which do not require the skill and training of a nurse • Vision training and vision therapy • Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP • Donor non-medical expenses • Charges incurred as a donor of an organ when the recipient is not covered under this health plan 11
CHIP Perinate Newborn & CHIP Perinate Covered Services CHIP Perinate Newborn & CHIP Perinate Covered Services Parkland CHIP Perinate Newborn & CHIP Perinate provides services as outlined below. Covered CHIP Perinatal services must meet the definition of Medically Necessary Covered Services. There is no lifetime maximum on benefits; however, 12-month enrollment period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays do not apply to CHIP Perinatal Members. CHIP Perinate Newborns are eligible for 12-months continuous coverage, beginning with the month of enrollment as a CHIP Perinate. Medically Necessary Services are health services that are: Physical Health: • reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical malformation or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of an unborn child, or endanger life of the unborn child; • provided at appropriate facilities and at the appropriate levels of care for the treatment of an unborn child’s medical conditions; • consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies; • consistent with diagnoses of the conditions; and • no more intrusive or restrictive than necessary to offer a proper balance of safety, effectiveness, and efficiency. Medically Necessary Services must be furnished in the most appropriate and least restrictive setting in which services can be safely provided and must be provided at the most appropriate level or supply of service which can safely be provided and which could not be omitted without adversely affecting the unborn child’s physical health and/or the quality of care provided. Emergency care is a covered CHIP Perinate service. “Emergency” and “emergency condition” means a medical condition of recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the condition, sickness, or injury is of such a nature that failure to get immediate care could result in: • placing the unborn child’s health in serious jeopardy; • serious impairment to bodily functions as related to the unborn child; • serious dysfunction of any bodily organ or part that would effect the unborn child; or • serious disfigurement to the unborn child. “Emergency services” and “emergency care” means health care services provided in an in-network or out-ofnetwork hospital emergency department or other comparable facility by in-network or out-of network doctors, providers, or facility staff to evaluate and stabilize medical conditions. Emergency services also include, but are not limited to, any medical screening examination or other evaluation required by state or federal law that is necessary to decide whether an emergency condition related to the labor and/or delivery of the covered unborn child exists. 12
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 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 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
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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,
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(2) post-partum visits within 60 da
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CHIP Member Enrollment and Disenrol
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• In order to synchronize all CHI
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Provider Participation Requirements
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• Evidence of state licensure, an
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U1 U2 U3 Medically necessary delive
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PROCEDURE DESCRIPTION PROCEDURE COD
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provider actually treating the memb
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themselves appropriately and follow
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Medical Record Standards The medica
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1. History and Physical Examination
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WIC services include providing nutr
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As soon as the member knows they wi
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3) by the director to the employee
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In addition to the previously state
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Prior Authorization The CHIP Perina
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Appendix A Universal Referral/Prior
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Appendix B Consent for Disclosure 1
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PERMISSION TO RELEASE CONFIDENTIAL
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EXAMPLE FORM PRIVATE PAY AGREEMENT
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Appendix D Clinical Practice Guidel
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Appendix D - Continued Clinical Pra
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Appendix D - Continued Clinical Pra
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RATIONALE: Attention-Deficit/ Hyper
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Appendix G Urinary Tract Infections
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Follow-up • Follow-up urine cultu
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RATIONALE: Prevention of RSV Illnes
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RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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