PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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• Donor non-medical expenses • Charges incurred as a donor of an organ when the recipient is not covered under this health plan 25
CHIP & CHIP PERINATAL DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members but are a benefit for CHIP Perinate Newborns. SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central 26 line kits/supplies. A self-injection kit used by patients highly allergic to bee stings. Ana Kit X Epinephrine Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Betadine X See IV therapy supplies. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication X Devices Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention. Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/<strong>Inc</strong>ontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing X Supplies/Central Line Dressing Supplies/Decubitus Dressing Supplies/Peripheral X X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit which includes all necessary items for one dressing site change. Eligible for coverage only if receiving covered home care for wound care. Eligible for coverage only if receiving home IV therapy.
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 30 and 31: • Personal comfort items includin
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
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 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 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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