PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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TABLE OF CONTENTS QUICK REFERENCE CHECKLIST .................................................................................................................................................... 1 DENTAL QUESTIONS OR DENTAL INFORMATION .................................................................................................................................... 1 INTRODUCTION ................................................................................................................................................................................... 2 PROVIDER MANUAL OVERVIEW .................................................................................................................................................... 4 OBJECTIVES OF PROGRAM ....................................................................................................................................................................... 4 ROLE OF PRIMARY CARE PROVIDER /MEDICAL HOME ............................................................................................................................... 4 ROLE OF SPECIALTY CARE PROVIDER ....................................................................................................................................................... 4 ROLE OF CHIP PERINATE PROVIDER ....................................................................................................................................................... 4 ROLE OF PHARMACY ................................................................................................................................................................................ 4 NETWORK LIMITATIONS ............................................................................................................................................................................ 4 CHIP COVERED SERVICES ................................................................................................................................................................ 5 CHIP PERINATE NEWBORN & CHIP PERINATE COVERED SERVICES.............................................................................. 12 CHIP PERINATE NEWBORN & CHIP PERINATE COVERED SERVICES ....................................................................................................... 12 CHIP PERINATAL COVERED SERVICES ................................................................................................................................................... 13 TEXAS AGENCY ADMINISTERED PROGRAMS AND CASE MANAGEMENT SERVICES ................................................ 29 ESSENTIAL PUBLIC HEALTH SERVICES .................................................................................................................................................... 29 BEHAVIORAL HEALTH .................................................................................................................................................................... 30 COORDINATION BETWEEN PHYSICAL AND BEHAVIORAL HEALTH SERVICES .............................................................................................. 31 MEDICAL RECORDS STANDARDS ............................................................................................................................................................. 31 CONSENT FOR DISCLOSURE OF INFORMATION ........................................................................................................................................ 31 COURT ORDERED COMMITMENTS .......................................................................................................................................................... 31 COORDINATION WITH THE LOCAL BEHAVIORAL HEALTH AUTHORITY ....................................................................................................... 31 ASSESSMENT INSTRUMENTS FOR BEHAVIORAL HEALTH ............................................................................................................................ 32 FOCUS STUDIES AND UTILIZATION REPORTING REQUIREMENTS .............................................................................................................. 32 MEMBER DISCHARGED FROM INPATIENT PSYCHIATRIC FACILITIES .......................................................................................................... 32 QUALITY IMPROVEMENT ............................................................................................................................................................... 32 INTRODUCTION ...................................................................................................................................................................................... 32 PRACTICE GUIDELINES .......................................................................................................................................................................... 33 PREVENTIVE HEALTH GUIDELINES ......................................................................................................................................................... 34 KEY PRACTICE MEASURES...................................................................................................................................................................... 34 FOCUS STUDIES AND UTILIZATION REPORTING REQUIREMENTS .............................................................................................................. 34 HIV/STD............................................................................................................................................................................................... 34 PROMPT ACCESS .................................................................................................................................................................................... 34 PCHP STAFF ......................................................................................................................................................................................... 35 PRIMARY CARE PROVIDER RESPONSIBILITIES ..................................................................................................................... 36 PRIMARY CARE SERVICES ....................................................................................................................................................................... 36 PROVIDER RESPONSIBILITIES ...................................................................................................................................................... 37 CONTRACT EFFECTIVE DATE.................................................................................................................................................................. 37 PROVIDER ACCESSIBILITY ...................................................................................................................................................................... 38 PRIMARY CARE PROVIDER ACCESS STANDARDS ...................................................................................................................................... 38 OTHER ACCESS STANDARDS ................................................................................................................................................................... 39 PHYSICIAN SELECTION/PRIMARY CARE PROVIDER CHANGES ................................................................................................................... 39 CHANGE IN MEMBER CAPACITY .............................................................................................................................................................. 39 ELIGIBILITY REPORT .............................................................................................................................................................................. 39 RESPONSIBILITY TO VERIFY MEMBER ELIGIBILITY AND/OR AUTHORIZATION FOR SERVICES....................................................................... 39 PRIOR AUTHORIZATION .......................................................................................................................................................................... 39 WHEN A MEMBER ACCESSES CARE ......................................................................................................................................................... 39 CHANGES IN MEDICAL OFFICE STAFFING AND ADDRESSES; .................................................................................................................... 40 i
Notification of Change in Provider Status ....................................................................................................................................... 40 PROVIDER TERMINATION FROM HEALTH PLAN ........................................................................................................................................ 40 MEMBERS RIGHT TO SELECT NETWORK OPHTHALMOLOGIST/ THERAPEUTIC OPTOMETRIST ..................................................................... 41 INITIAL CHECKUPS UPON ENROLLMENT.................................................................................................................................................. 41 TEXAS VACCINES FOR CHILDREN (TVFC) ............................................................................................................................................... 41 PHYSICIAN SPECIALIST CARE .................................................................................................................................................................. 41 LABORATORY TESTS ............................................................................................................................................................................... 41 NEWBORN EXAMINATIONS ...................................................................................................................................................................... 41 CHILDREN WITH CHRONIC AND COMPLEX CONDITIONS .......................................................................................................................... 41 HMO/PROVIDER COORDINATION ........................................................................................................................................................... 43 OBSTETRICIAN/GYNECOLOGIST SERVICES ............................................................................................................................................... 43 HEALTH PLAN LIMITS TO NETWORK ....................................................................................................................................................... 43 ADVANCE DIRECTIVES – PHYSICIANS ...................................................................................................................................................... 44 ADVANCE DIRECTIVES – MEMBERS ......................................................................................................................................................... 45 REFERRAL TO SPECIALISTS AND HEALTH-RELATED SERVICES .................................................................................................................. 45 PCP AND BEHAVIORAL HEALTH ............................................................................................................................................................. 46 REFERRAL TO NETWORK FACILITIES AND CONTRACTORS ......................................................................................................................... 46 ACCESS TO SECOND OPINION ................................................................................................................................................................. 46 COORDINATION OF CARE ....................................................................................................................................................................... 47 CONTINUITY OF CARE PREGNANT WOMEN .............................................................................................................................................. 47 MEMBER MOVES OUT OF SERVICE AREA ................................................................................................................................................ 47 PRE-EXISTING CONDITIONS .................................................................................................................................................................... 47 MEDICAL RECORD STANDARDS .............................................................................................................................................................. 48 OUT-OF-NETWORK REFERRALS .............................................................................................................................................................. 48 COORDINATION WITH TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES (TDFPS) .................................................................. 49 HOSPITAL TRANSFERS ............................................................................................................................................................................ 49 COMPLIANCE WITH PCHP POLICY AND PROCEDURES ............................................................................................................................ 49 PHARMACY BENEFITS ...................................................................................................................................................................... 49 PREFERRED DRUG LIST .................................................................................................................... ERROR! BOOKMARK NOT DEFINED. FORMULARY DRUG LIST .................................................................................................................... ERROR! BOOKMARK NOT DEFINED. OVER THE COUNTER DRUGS ............................................................................................................. ERROR! BOOKMARK NOT DEFINED. MAIL ORDER FORM FOR YOUR MEMBERS ........................................................................................... ERROR! BOOKMARK NOT DEFINED. PROCEDURE FOR OBTAINING PHARMACY PRIOR AUTHORIZATION ..................................................... ERROR! BOOKMARK NOT DEFINED. EMERGENCY PRESCRIPTION SUPPLY ........................................................................................... ERROR! BOOKMARK NOT DEFINED. VISION SERVICES .............................................................................................................................................................................. 49 ROUTINE, URGENT, AND EMERGENCY SERVICES ................................................................................................................. 50 ROUTINE CARE ...................................................................................................................................................................................... 50 URGENT CARE ....................................................................................................................................................................................... 50 EMERGENCY CARE ................................................................................................................................................................................. 50 PRESENTATION AT EMERGENCY ROOM AFTER HOURS ............................................................................................................................. 51 PRESENTATION AT EMERGENCY ROOM DURING NORMAL BUSINESS HOURS.............................................................................................. 51 EMERGENCY SERVICES AND CARE .......................................................................................................................................................... 51 EMERGENCY ADMISSION ........................................................................................................................................................................ 51 EMERGENCY AMBULANCE SERVICES ....................................................................................................................................................... 51 NON-EMERGENCY AMBULANCE SERVICE ................................................................................................................................................ 51 EMERGENCY PRESCRIPTION SUPPLY ....................................................................................................................................................... 52 DEFINITION OF EMERGENCY TRANSPORTATION ...................................................................................................................................... 52 NON-EMERGENCY MEDICAL TRANSPORTATION ....................................................................................................................................... 52 CHIP EMERGENCY DENTAL SERVICES: .................................................................................................................................................. 52 PROVIDER COMPLAINTS AND APPEALS PROCESS ................................................................................................................ 52 PROVIDER COMPLAINTS TO HMO .......................................................................................................................................................... 52 PROVIDER APPEAL PROCESS TO HMO ................................................................................................................................................... 53 PROVIDER COMPLAINT PROCESS TO THE STATE ...................................................................................................................................... 53 CHIP MEMBER COMPLAINTS/APPEAL PROCESS .................................................................................................................... 53 MEMBER COMPLAINTS TO HMO ............................................................................................................................................................ 53 MEMBER COMPLAINT APPEAL PROCESS TO HMO................................................................................................................................ 54 ii
Page 1: Parkland KIDSfirst, Parkland CHIP P
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 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
Page 73 and 74:
your income. Co-payments do not app
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Member’s Right to Designate an OB
Page 77 and 78:
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
Page 93 and 94:
(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
Page 101 and 102:
Provider Participation Requirements
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• 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
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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
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In addition to the previously state
Page 125 and 126:
Prior Authorization The CHIP Perina
Page 127 and 128:
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
Page 135 and 136:
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
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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