PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Covered Benefit CHIP Perinate Newborn CHIP Perinate Inpatient Mental Health Services Mental health services, including for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities, including, but not limited to: Not a covered benefit. • Neuropsychological and psychological testing. • When inpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination • Does not require PCP referral Outpatient Mental Health Services Mental health services, including for serious mental illness, provided on an outpatient basis, including, but not limited to: • The visits can be furnished in a variety of community-based settings (including school and home-based) or in a state-operated facility • Neuropsychological and psychological testing • Medication management • Rehabilitative day treatments • Residential treatment services • Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment) • Skills training (psycho-educational skill development) • When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination Not a covered benefit. 19
Covered Benefit CHIP Perinate Newborn CHIP Perinate • A Qualified Mental Health Provider – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1, §412.303(48). QMHP-CSs shall be providers working through a DSHScontracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and group skills training (which can be components of interventions such as day treatment and inhome services), patient and family education, and crisis services • Does not require PCP referral 20 Inpatient Substance Abuse Treatment Services Outpatient Substance Abuse Treatment Services Rehabilitation Services Services include, but are not limited to: • Inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs • Does not require PCP referral Services include, but are not limited to, the following: • Prevention and intervention services that are provided by physician and nonphysician providers, such as screening, assessment and referral for chemical dependency disorders. • Intensive outpatient services • Partial hospitalization • Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day • Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training • Does not require PCP referral Services include, but are not limited to, the following: • Habilitation (the process of supplying a child with the means to reach ageappropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following: Not a covered benefit. Not a covered benefit. Not a covered benefit.
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 28 and 29: 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
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
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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
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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