PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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statement indicating that members seeking STD/HIV services at a public health clinic can do so without seeking prior authorization. • Payment of claims for STD/HIV services provided to members by out-of-network providers will be contingent on the transfer of treatment information by the provider to Parkland KIDSfirst and Parkland CHIP Perinate Newborn. • Treatment information related to STD/HIV services provided to members by out-of-network providers will be transferred to the member’s Primary Care Provider by the Parkland KIDSfirst and Parkland CHIP Perinate Newborn Medical Director. PCHP Staff • The PCHP Staff Orientation and Employee Handbook will contain statements regarding the responsibility of the PCHP staff to keep member medical records and information secure and confidential. These statements will include information on the penalties imposed for breaching member confidentiality. • Member records and member information in PCHP possession, including information related to STD/HIV treatment or services received by the member, will be maintained under supervision during business hours and secured in locked file cabinets or a locked room during hours when the facility is closed for business. • Member medical records will be available only to PCHP staff in working directly with clinical matters, claims processing, or other payment related data included in the medical record. • PCHP must obtain the member’s written consent to release information to individuals or entities outside of PCHP when disclosure of records is requested. • Requests for release of member information related to STD/HIV treatment or services received by the member from outside Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn must be directed to the Medical Director. • Requests for release of information will be recorded by the Medical Director’s office. • If a properly executed written consent form does not accompany the request, the request will be denied in writing. The written denial will contain the reason for the denial and instructions on how to request the information properly. A copy of the denial will be returned to the member. • If the request for member information is accompanied by a properly executed request for release of information, the Medical Director will send the information if it is available in the facility. If not, the Medical Director will refer the request to the member’s Primary Care Provider for action. This information will be addressed to the requesting official via First Class U.S. mail in a sealed envelope marked CONFIDENTIAL. A copy of the letter accompanying the released information will be sent to the member and the member’s Primary Care Provider. • PCHP members can review or obtain their own health care information by sending a written signed request to the PCHP Medical Director. The request must include the member’s name, date of birth, member ID number. A copy of the request will be forwarded to the member’s Primary Care Provider. • PCHP will respond in writing, within 5 business days of the date of receipt of the request, to written request by the member who asks to review their health care information. 35
• If the member wishes to view the information and it is available within the Parkland KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn facility, an appointment will be made for them during regular business hours. The member will be advised to bring current picture identification. Members who properly identify themselves will be allowed to see their health care information. • Members who ask for a copy of their health care information can do so at no charge to the member. Primary Care Provider Responsibilities Primary Care Services The Primary Care Provider provides a medical home for the member and arranges for health care needs of the PCHP members. Primary Care Providers can include providers who specialize in General Practice, Family Practice, Internal Medicine, Obstetrics/Gynecology, or Pediatrics. Advanced Nurse Practitioners and Physician Assistants (practicing under the supervision of a physician specializing in Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology) Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can also qualify as Primary Care Providers. When joining PCHP, each member picks a Primary Care Provider who participates in the PCHP network. The Primary Care Provider will provide covered services for the member, arrange for any required specialty referral, and obtain pre-authorization from PCHP for any inpatient hospitalization and procedures on the Prior Authorization list. Providers should refer members to network facilities and contractors. To learn more, please see the Referrals section of this manual. Participating providers will abide by the policies regarding preventive care and health education to members during each office visit, and will document such services in the member’s medical records. As the Primary Care Provider you must provide primary care services and continuity of care to members who are enrolled with or assigned to you. Primary Care Services are all services that provide for the prevention, detection, treatment and cure of illness, trauma, disease or disorder, which are covered and or required services under the contract. All services must be provided in compliance with generally accepted medical and behavioral health standards for the community in which services are rendered. Primary Care Providers must provide services to children under the age of 19 in accordance with the American Academy of Pediatrics periodicity schedule and the United States Preventative Services Task Force’s publication Put Prevention Into Practice. As the Primary Care Provider, you must assess the medical needs of members for referral to specialty care providers and give referrals as needed. Primary Care Providers must coordinate care with specialty care providers after referral. As the Primary Care Provider, you must insure integration of member’s medical home needs with home and community resources which provide medical, nutritional, behavioral, educational and outreach services available to members. As the Primary Care Provider, you must provide or arrange for pre-admission planning for non-emergency inpatient admissions, and discharge planning for members. As the Primary Care Provider, you must call the emergency room with relevant information about the member when necessary. 36
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 40 and 41: in the provision of care and servic
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
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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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