PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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in the provision of care and service to Parkland KIDSfirst, Parkland CHIP Perinate, and Parkland CHIP Perinate Newborn members. Final authority for implementation of the Quality Program rests with the governing board. The monitoring and evaluation of clinical care reflects all components of the delivery system and the full range of services. The delivery system includes both individual practitioners and institutional providers. The monitoring and evaluation of services includes availability (number and geographic distribution of practitioners, appointment availability, etc.), accessibility (practitioners and PCHP phone systems, after-hours coverage, etc.), and acceptability (appropriate services delivered in the appropriate manner). PCHP annually assesses the effectiveness of its QAPI Program for the previous SFY measurement period, supported by presentation of results, analysis, and actions taken in the measurement period. Meaningful issues are selected for study and improvement based on the health needs of significant groups within the population. Ongoing improvement issues include improving preventive health visits, reducing unnecessary emergency room visits, improving access and availability of care, and perinatal care. Continuity and coordination of care is evaluated across health care settings and practitioners. Methods can include medical record review for presence of advance directives, discharge plans, and signing of abnormal test results; evaluation of the referral process, case management interventions, systems for tracking and notifying practitioners of abnormal lab/radiology results. Mechanisms are also in place to identify patterns of under- and over- utilization. Methods can include doctor profiles, review of practitioner performance against practice guidelines, trending and tracking of complaint data, sentinel events and adverse outcomes, and number of member encounters per Primary Care Provider. Access and availability of care are monitored through appointment availability for preventive care, routine primary care and urgent care, 24 hours access, number and geographic distribution of Primary Care Providers, and phone service standards. All aspects of member care and satisfaction are important to Parkland KIDSfirst, Parkland CHIP Perinate, and Parkland CHIP Perinate Newborn. Provider participation in PCHP and CHIP sponsored training programs as well as the aforementioned issues are carefully scrutinized and Parkland KIDSfirst, Parkland CHIP Perinate, and Parkland CHIP Perinate Newborn work in conjunction with the cooperation of their doctor and facility partners to maintain a program of the highest quality. PCHP complies with all HHSC and Texas Department of Insurance (TDI) requirements pertaining to the QAPI Program. Practice Guidelines Clinical Practice Guidelines summarize evidence based management and treatment options for specific diseases or conditions. They are based on scientific clinical and expert consensus information from nationally recognized sources and organizations such as the National Institute of Health, the American Academy of Pediatrics, the center or Disease Control and Prevention, the National Heart Lung and Blood Institute, the American College of Obstetrics and Gynecology, national disease associations and peer-reviewed, published literature. Practice guidelines are developed from national guidelines and adopted locally through the Medical Advisory Committee that includes practicing physicians who participate in the Plan. This group also suggests topics for guideline development, based on relevance to enrolled membership, with selection of high volume, high risk, problem prone conditions as the first priority. PCHP guidelines can be located in the appendices of this Provider Manual. The intent of the guideline is to promote consistent application of evidence-based treatment methodologies to reduce unnecessary practice variation. Guidelines are also used to measure the impact of health management 33
programs on outcomes. The guidelines are provided for informational purposes and are not intended to direct individual treatment decisions. All patient care and related decisions are the sole responsibility of physicians or health care professionals, and these guidelines do not dictate or control the clinical judgment of the health care professionals caring for a member. Preventive Health Guidelines Preventive health recommendations are adopted from federal agencies and medical professional organizations. Providers delivering well-child care to PCHP members are encouraged to use the American Academy of Pediatrics (AAP) preventive health guidelines. AAP Guidelines are located in the appendices in this manual. The recommended childhood and adolescent immunization schedule of the AAP is issued annually and available online at www.aap.org. Key Practice Measures Key Practice Measure Reports are prepared for Primary Care Physicians (PCPs) and other selected providers at least annually. The Plan issues reports to providers with a selected minimum number of active members on their panels in a 12 month period. Reports for PCPs may include such measures as appropriate care for diabetics and asthmatics, appropriate use of antibiotics, access measures, utilization measures, and complaints. Measures for other specialties are based on specialty type. 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. HIV/STD Parkland KIDSfirst and Parkland CHIP Perinate Newborn will provide to its members, through its network, all STD/HIV services and treatments that are necessary and appropriate. STD/HIV services will include STD/HIV prevention, screening, counseling, diagnosis, and treatment. All records and member information related to the provision of these services will be kept confidential. Prior authorization will not be needed for members who wish to seek STD/HIV services at a public health clinic. Prompt Access • Parkland KIDSfirst and Parkland CHIP Perinate Newborn Network Development Department will develop a network of public and private hospitals, doctors, and other providers experienced in providing all covered STD/HIV procedures and services. The network will include providers located throughout the Service Area, as well as Significant Traditional Providers (STPs) available for providers. • Parkland KIDSfirst and Parkland CHIP Perinate Newborn will provide training and education available for providers on the prevention, detection, and effective treatment of STD/HIV. • The Parkland KIDSfirst and Parkland CHIP Perinate Newborn Member Handbook will include clear statements indicating how and where members can obtain confidential STD/HIV services and will include a 34
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 38 and 39: Coordination between Physical and B
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,
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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
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
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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
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
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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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