PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS Supplies catheter ordered by the Primary Care Provider and approved by the plan Urinary, Indwelling Catheter and X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Supplies Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Texas Agency Administered Programs and Case Management Services The following are services that are not a part of Parkland CHIP Program services; however, Parkland KidsFirst, Parkland CHIP Perinate and/or CHIP Perinate Newborn members can also qualify for: • The Children’s Education Fund (CEF). CEF can provide families with help in paying tuition for children who are in kindergarten through eighth grade. Families might qualify for tuition scholarships up to $1000 for Dallas County residents. • Early Childhood Intervention Program (ECI). ECI can offer services in the home or in the community for children, birth to three years old who are developmentally delayed. Some of the services for children include: screenings, physical, occupational, speech and language therapy, and activities to help children learn better. • DSHS Targeted Case Management Programs. DSHS can offer various mental health and mental retardation programs, such as psychiatric treatment, child and adolescent counseling, and crisis intervention. • Women, Infants, and Children (WIC) Program. WIC can help infants and children under five years old, and pregnant and breastfeeding women who qualify to get nutritious food, nutrition education, and counseling. Essential Public Health Services Parkland Community Health Plan is required through its contractual relationship with HHSC to coordinate with public health entities regarding the provision of services for essential public health services. Providers must help PCHP in these efforts by: • Complying with public health reporting requirements regarding communicable diseases and/or disease which are preventable by immunizations as defined by state law. • Assisting in notifying or referring to the local Public Health Entity, as defined by state law, any communicable disease outbreaks involving members, • Referring to the local Public Health Entity for tuberculosis (TB) contact investigation and evaluation and preventive treatment of persons whom the member has come into contact. • Referring to the local Public Health Entity for STD/HIV contact investigation and evaluation and preventive treatment of persons whom the member has come into contact. • Referring for Women, Infant and Children (WIC) services and information sharing. • Assisting in the coordination and follow-up of suspected or confirmed cases of childhood lead exposure. • Reporting of immunizations provided to the statewide ImmTrac Registry including parental consent to share data. • Cooperating with activities required of public health authorities to conduct the annual population and community based needs assessment. • Referring lead screening tests to the DSHS Laboratory. 29
Behavioral Health Behavioral Health services are covered benefits for Parkland KidsFirst and Parkland CHIP Perinate Newborn members as indicated in the Scope of Services grid starting on page 6 and as described in the paragraphs below. Behavioral Health services are not a covered benefit for Parkland CHIP Perinate members. In addition to medical care, limited Behavioral Health care services are available for Parkland KidsFirst and Parkland CHIP Perinate Newborn members. Behavioral Health is defined as those services provided for the assessment and treatment of problems related to mental health and substance abuse. Substance abuse includes abuse of alcohol and other drugs. Primary Care Providers can offer behavioral health treatment to members within the scope of their practice. A complete listing of the Behavioral Health services available to Parkland KidsFirst and Parkland CHIP Perinate Newborn members is located in the Scope of Services grid. Parkland KidsFirst and Parkland CHIP Perinate Newborn ensures that the care of newly enrolled members is not disrupted or interrupted. Parkland KidsFirst and Parkland CHIP Perinate Newborn must take special care to provide continuity in the care of newly enrolled members whose physical health or behavioral health condition has been provided by specialty care providers or whose health could be placed in jeopardy if care is disrupted or interrupted. Parkland KidsFirst and Parkland CHIP Perinate Newborn are committed to coordinating medical and behavioral care for members who will be appropriately screened, evaluated, treated and/or referred for physical health or behavioral health. Parkland KidsFirst and Parkland CHIP Perinate Newborn have designated a Behavioral Health liaison to help with coordination of care and case management efforts. Parkland KidsFirst members can self-refer to a participating Behavioral Health specialist by calling the CompCare Behavioral Health Hotline listed on page 1 of this manual. Parents of Parkland CHIP Perinate Newborn members should call Member Services at 1-888-814-2352. Ask for the Patient Management Department for assistance. Parkland KidsFirst and Parkland CHIP Perinate Newborn promotes early intervention and health screening for identification of behavioral health problems and patient education. To that end, Parkland KidsFirst and Parkland CHIP Perinate Newborn providers are expected to: • Screen, evaluate, treat and/or refer (as medically appropriate), any behavioral health problem/disorder; • Primary Care Provider can treat for mental health and/or substance abuse disorders within the scope of their practice; • Tell members how and where to obtain Behavioral Health services; Continuity and coordination of care is vital to assuring that members receive appropriate and timely care. The provider and participating specialists are expected to talk often regarding the health care services provided to each member. Copies of prior authorization/referral forms and other relevant communication between the specialist and the Primary Care Provider should be maintained in both providers’ files for the member. Providers must use DSM-IV multi-axial classifications and other assessment instruments or outcome measures required by HHSC when assessing member for behavioral health services. Parkland KidsFirst and Parkland CHIP Perinate Newborn also requires that all members receiving inpatient psychiatric services must be scheduled for outpatient follow-up and/or continuing treatment before discharge. The outpatient treatment must happen within seven days from the date of discharge. CompCare providers will follow-up with CHIP members within 24 hours and try to reschedule missed appointments. 30
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 32 and 33: • Donor non-medical expenses •
Page 34 and 35: 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
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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
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
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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
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provider actually treating the memb
Page 111 and 112:
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
Page 119 and 120:
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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