PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

More documents

Recommendations

Info

As the Primary Care Provider you must provide or arrange for follow-up care after emergency or inpatient care. As the Primary Care Provider, you can provide Behavioral Health services within your scope of practice. Primary Care Providers for children under the age of 19 must ensure that the member receives all services required for Early Childhood Intervention (ECI), prenatal care, WIC, children with disabilities or chronic or complex conditions, and health education and wellness where applicable. Primary Care Providers will provide services such as well child health checkup in accordance with the American Academy of Pediatric recommendations. The Primary Care Provider has the following responsibilities: • All PCHP participating Primary Care Providers, groups, and/or extenders shall provide all primary care covered services within the scope of the physician’s practice as required by his/her membership panel and as outlined in the “Physician Agreement.” • A Primary Care Provider is responsible for providing or arranging for the provision of services to members assigned to their panel. • The Primary Care Provider is responsible for seeking prior authorization from PCHP when referring to non-participating providers. • When prior-authorization is required, the Primary Care Provider or admitting doctor will begin the request. • The Primary Care Provider recognizes the role that the family members have as primary caregivers for children and other dependents and assures their participation in decision making. Provider Responsibilities The Primary Care Provider will: • Provide appropriate health education and instructions to the member or member guardian as appropriate. • Assure appropriate transfer of medical information between the primary care providers, specialty care providers, and ancillary care providers. • Assure that discharge planning is conducted for each admitted member. • Assure that pre-admission planning occurs for the member in all non-emergency hospital admissions. • Assure that the home and community arrangements are available before the hospital discharge of the member in need of home health services. • Provide information concerning appropriate support services (e.g., WIC, DHS, ECI, etc) within the community. • Provide after hours call coverage. • Provide assistance with hospital arrangements; including meeting members in the Emergency Room (ER) or calling the ER with relevant information about the member. • Help in the development of alternatives to hospitalization when medically appropriate. • Provide timely follow-up after emergency care or hospitalization. • Follow the Plan guidelines, including updated changes, benefits, limitations to program, etc. Contract Effective Date New providers who enter into a valid contract and have been credentialed by PCHP will be assigned a network participation effective date. The provider’s effective date will be fifteen (15) business days from the date the provider was credentialed or the date a valid contract and documentation was received by PCHP, whichever is later. 37
For existing KIDSfirst providers that have notified HEALTHfirst of their request to be added as STAR participating providers, provider’s effective date will be fifteen (15) business days from the date valid documentation was received by PCHP. Provider Accessibility Each Primary Care shall provide covered services at their offices during normal business hours. Covered services shall be available and accessible to members, including phone access, 24 hours a day, seven days per week, to advise members how and where to access urgent or emergency services. The Primary Care Provider shall arrange for appropriate coverage with other PCHP participating providers if he/she is unavailable due to vacation, illness, or leave of absence. The following are acceptable and unacceptable phone arrangements for contacting Primary Care Providers after normal business hours. Acceptable: 1. Office Phone is answered after hours by an answering service. All calls answered by an answering service must be returned by a provider within 30 minutes. 2. Office phone is answered after normal business hours by a recording in the language of each of the major population groups served and directs the patient to call another number to reach the Primary Care Provider or another provider designated by you. Someone must be available to answer the designated provider’s phone. Another recording is not acceptable. 3. Office phone is transferred after office hours to another location where someone will answer the phone and be able to contact the Primary Care Provider or another designated medical practitioner. Unacceptable: 1. Office phone is only answered during office hours. 2. Office phone is answered after hours by a recording, which informs the patients to leave a message. 3. Office phone is answered after hours by a recording which directs patients to go to an emergency room for any services needed. 4. Returning after-hour calls outside of 30 minutes. Primary Care Provider Access Standards The following are the established PCHP appointment availability standards for primary care providers: Appointment Type New Member ‣ Newborns ‣ Children Preventive Care ‣ Newborns ‣ Children Routine Primary Care Urgent Medical Care Emergency Care Prenatal Care Initial Behavioral Health Care Standard New members should be offered appointments as soon as possible after enrollment but in no case later than within: ‣ 14 days of enrollment for newborns ‣ 60 days of enrollment for all other eligible child members Well child checkups should be scheduled in accordance with the AAP periodicity schedule for preventive health care services. Within 14 days of request Within 24 hours of request Upon presentation Within 14 days of request, except for high risk pregnancies or new members in the third trimester for whom an appointment must be offered within 5 days, or immediately, if an emergency exists Within 14 days of request 38
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 42 and 43: statement indicating that members s
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
show all

PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?