PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Other Access Standards
Service
Standard
Referrals Routine specialty care referrals must be provided within 30
days of request
After hours
Coverage must be available after normal posted business hours
7 days a week, 365 days a year
After hours calls returned < 30 minutes
In-office wait time
< 30 minutes
Physician Selection/Primary Care Provider Changes
Each CHIP eligible person who joins PCHP selects a Primary Care Provider who serves as the member’s
personal doctor. The Primary Care Provider is responsible for coordinating all aspects of that member’s
medical care, including referrals to participating specialists. Each enrolled member within a family can pick
different Primary Care Providers. If an eligible member fails to pick a Primary Care Providers the health plan
will assign a Primary Care Provider for the member.
Members can elect to change their Primary Care Provider four (4) times per year. Likewise, participating
PCHP providers can ask for a member transfer to another participating provider in the event of material
breakdown in the doctor/patient relationship. These reasons can include frequently missed appointments
without calling the provider’s office and ignoring the advice of the provider. PCHP will work collaboratively
with the provider and the member to restore the provider/patient relationship or honor the request for a change.
Change in Member Capacity
PCHP will monitor provider access to assure that members are able to receive timely care. The Texas Health
and Human Services Commission (HHSC) will in turn monitor PCHP’s member accessibility and quality of
care. If HHSC finds out that the provider is unable to provide acceptable care and access to current
membership, the membership will be reduced through an enrollment freeze. If the quality of care for members
is jeopardized, HHSC can disenroll members from the provider.
Eligibility Report
PCHP will supply each Primary Care Provider with a monthly member eligibility listing within five (5) working
days of PCHP’s receipt of enrollment information from the CHIP Administrative Contractor. The Primary Care
Provider shall be responsible for providing and/or coordinating care for the identified members on the report.
Responsibility to Verify Member Eligibility and/or Authorization for Services
All members are issued a PCHP ID card at the time of enrollment with us. Eligibility should be verified before
rendering services through the following resources:
• Utilize the PCHP website at www.parklandhmo.org
• Contact PCHP Member Services
Prior Authorization
The Primary Care Provider might need to obtain prior authorization from PCHP before initiating certain
procedures, admissions or specialty services. Please review the list of services and procedures requiring prior
authorization as documented in the “Prior Authorization” section of this manual.
When a Member Accesses Care
What to do when a PCHP member presents for services:
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