PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Coordination between Physical and Behavioral Health Services Parkland KidsFirst is committed to coordinating medical and behavioral care for members who will be appropriately screened, evaluated, treated and/or referred for physical health, behavioral health or substance abuse, dual or multiple diagnoses, mental retardation, or developmental disabilities. KidsFirst will designate behavioral health liaison personnel to facilitate coordination of care and case management efforts. The provider and participating specialists are expected to communicate frequently regarding the health care 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. Coordination of care is vital to assuring members receive appropriate and timely care. Compliance with this coordination is reviewed closely during site visits for credentialing and recredentialing, as well as during quality improvement and utilization management reviews. Parkland KidsFirst ensures that the care of newly enrolled members is not disrupted or interrupted. Parkland KidsFirst 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. Medical Records Standards Medical records must reflect all aspects of patient care, including ancillary services. Participating providers and other health care professionals agree to maintain medical records in a current, detailed, organized and comprehensive manner in accordance with customary medical practices, applicable laws, and accreditation standards. Medical records must reflect all aspects of patient care, including ancillary services. Detailed information on Medical Records Standards can be found later in this manual. Consent for Disclosure of Information An authorization to release confidential information, such as medical records regarding treatment, should be signed by the patient before receiving care from a behavioral health provider. In order to adhere to the continuity of care between the Primary Care Provider, specialist, and/or behavioral health provider, sharing of medical history regarding a patient’s health is necessary. This can be done using the “Consent for Disclosure of Confidential Information” form. Court Ordered Commitments A “Court Ordered Commitment” means a confinement of a member to a psychiatric facility for treatment that is ordered by a court of law pursuant to the Texas Health and Safety Code, Title VII, Subtitle C. Parkland Community Health Plan (PCHP) and CompCare are required to provide inpatient psychiatric services to members under the age of 21, up to the yearly limit, who have been ordered to receive the services by a court of competent, jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, related to Court Ordered Commitments to psychiatric facilities. PCHP and CompCare will not deny, reduce or controvert the medical necessity of inpatient psychiatric services provided pursuant to a Court Ordered commitment for members under age 21. Coordination with the Local Behavioral Health Authority PCHP and CompCare will coordinate with the Local Behavioral Health Authority (LBHA) and state psychiatric facilities regarding admission and discharge planning, treatment objectives and projected length of stay for members committed by a court of law to the state psychiatric facility. PCHP and CompCare will meet the rules with additional behavioral health services requirements about coordination with the LBHA and care for special populations. Covered services will be provided to members with Severe and Persistent Mental Illness 31
(SPMI)/Severe Emotional Disturbance (SED) when medically necessary, whether or not they are receiving targeted case management or rehabilitation services through the LBHA. PCHP works with CompCare and other participating behavioral health care practitioners, Primary Care Providers, medical/surgical specialists, organizational providers and other community and state resources to develop relevant primary and secondary prevention programs for behavioral health. These programs can include: • educational programs to promote prevention of substance abuse • parenting skills training • developmental screening for children • ADHD screening • postpartum depression screening • depression screening in adults Assessment Instruments for Behavioral Health In addition to the screening tools provided in the Texas Medicaid Provider Procedures Manual, copies of additional tools are included in the Appendices of this manual. Focus Studies and Utilization Reporting Requirements Parkland KidsFirst and Parkland CHIP Perinate Newborn has integrated behavioral health into its Quality Assessment and Performance Improvement (QAPI) Program to ensure a systematic and ongoing process for monitoring, evaluating and improving the quality and appropriateness of behavioral health services provided to our members. A special focus of these activities is the improvement of physical health outcomes resulting from behavioral health integration into the member’s overall care. PCHP will routinely monitor claims, encounters, referrals and other data for patterns of potential over and under utilization, and target areas where opportunities to promote efficient and effective use of services exist. Compliance with coordination-of-care requirements is reviewed closely during site visits for credentialing and recredentialing, as well as during quality improvement and utilization management reviews. Member Discharged from Inpatient Psychiatric Facilities Parkland KidsFirst requires that all members receiving inpatient psychiatric services must be scheduled for outpatient follow-up and/or continuing treatment prior to discharge. The outpatient treatment must occur within seven (7) days from the date of discharge. CompCare providers will follow up with Medicaid members and attempt to reschedule missed appointments. Quality Improvement Introduction The Quality Assessment and Performance Improvement (QAPI) Program is comprehensive in scope, including both the quality of clinical care and service and all aspects of the Parkland KIDSfirst, Parkland CHIP Perinate, and Parkland CHIP Perinate Newborn delivery system. It is tailored to the unique needs of the membership, in terms of age groups, disease categories, special risk status and product line. The QAPI Program is directed by a multi-disciplinary Committee composed of members who bring a diversity of knowledge and skills to the design, oversight, and evaluation of the program. The Quality Improvement Committee (QIC) and other sub-committees include both clinical practitioners and other staff who are involved 32
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 36 and 37: SUPPLIES COVERED EXCLUDED COMMENTS/
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,
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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
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
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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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