PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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MEMBER EXPEDITED APPEAL PROCESS TO HMO ................................................................................................................................. 54 MEMBER ADVERSE DETERMINATION APPEAL PROCESS TO HMO ........................................................................................................ 55 INDEPENDENT REVIEW ORGANIZATION (IRO) PROCESS....................................................................................................................... 56 CHIP ELIGIBILITY ............................................................................................................................................................................. 57 CHIP KIDSFIRST MEMBERS ................................................................................................................................................................... 57 PREGNANT TEENS .................................................................................................................................................................................. 57 PARKLAND CHIP PERINATE AND PARKLAND CHIP PERINATE NEWBORN MEMBERS ................................................................................ 58 CHIP MEMBER ENROLLMENT AND DISENROLLMENT......................................................................................................... 58 ENROLLMENT APPLICATION ................................................................................................................................................................ 58 ENROLLMENT PROCESS ...................................................................................................................................................................... 58 RE-ENROLLMENT ................................................................................................................................................................................ 59 DISENROLLMENT ................................................................................................................................................................................. 59 PLAN CHANGES ................................................................................................................................................................................... 60 CHIP PERINATAL MEMBER ENROLLMENT AND DISENROLLMENT ................................................................................ 60 ENROLLMENT ....................................................................................................................................................................................... 60 NEWBORN PROCESS ........................................................................................................................................................................... 60 PLAN CHANGES ................................................................................................................................................................................... 60 DISENROLLMENT ................................................................................................................................................................................. 60 PARKLAND COMMUNITY HEALTH PLAN MEMBER IDENTIFICATION CARD ............................................................... 62 IDENTIFICATION CARDS ......................................................................................................................................................................... 62 PREGNANT TEENS .................................................................................................................................................................................. 64 SPELL OF ILLNESS .................................................................................................................................................................................. 64 VALUE ADDED SERVICES & EXTRA BENEFITS ........................................................................................................................ 64 VALUE-ADDED SERVICES ........................................................................................................................................................................ 64 EXTRA BENEFITS .................................................................................................................................................................................... 65 MEMBER RIGHTS AND RESPONSIBILITIES ............................................................................................................................... 65 MEMBER RIGHTS ................................................................................................................................................................................... 65 MEMBER RESPONSIBILITIES .................................................................................................................................................................... 66 PARKLAND CHIP PERINATE MEMBER RIGHTS AND RESPONSIBILITIES ....................................................................... 67 MEMBER’S RIGHT TO DESIGNATE AN OB/GYN ....................................................................................................................................... 68 FRAUD REPORTING .......................................................................................................................................................................... 68 FRAUD AND ABUSE ................................................................................................................................................................................ 68 INVESTIGATION OF FRAUD/ABUSE .......................................................................................................................................................... 68 MEDICAL RECORD REVIEW .................................................................................................................................................................... 68 REPORTING MEMBER AND PROVIDER FRAUD AND ABUSE TO THE OIG .................................................................................................... 69 MEMBER, PROVIDER, AND STAFF EDUCATION ........................................................................................................................................ 69 HHSC REGULATORY REQUIREMENTS FOR FRAUD AND ABUSE ................................................................................................................ 70 STATE AND FEDERAL FALSE CLAIMS ACTS AND WHISTLEBLOWER PROTECTIONS ...................................................................................... 72 SPECIALIST RESPONSIBILITIES ................................................................................................................................................... 72 APPOINTMENT AVAILABILITY .................................................................................................................................................................. 73 RESPONSIBILITY TO VERIFY MEMBER ELIGIBILITY AND/OR AUTHORIZATION FOR SERVICES....................................................................... 73 SPECIALIST AS PRIMARY CARE PROVIDER – CHRONIC OR COMPLEX CONDITIONS .................................................................................... 73 WHEN A MEMBER ACCESSES CARE ......................................................................................................................................................... 74 EMERGENCY SERVICES AND CARE .......................................................................................................................................................... 74 NOTIFICATION OF CHANGES IN MEDICAL OFFICE STAFFING AND ADDRESSES; ........................................................................................ 74 LABORATORY TESTS ............................................................................................................................................................................... 75 REFERRALS ............................................................................................................................................................................................ 75 PRIOR AUTHORIZATION .......................................................................................................................................................................... 75 SPECIALTY SERVICES AVAILABLE WITHOUT REFERRAL ............................................................................................................................. 75 ACCESS TO A SECOND OPINION .............................................................................................................................................................. 76 CLAIMS SUBMISSION ........................................................................................................................................................................ 76 iii
CLAIMS SUBMISSION .............................................................................................................................................................................. 76 PAPER CLAIMS ....................................................................................................................................................................................... 76 CLAIMS FORMS ...................................................................................................................................................................................... 76 SPECIALIST PHYSICIAN AND ALLIED HEALTH PROFESSIONALS ................................................................................................................. 79 EMERGENCY SERVICES CLAIMS .............................................................................................................................................................. 79 COST SHARING SCHEDULE FOR PARKLAND KIDSFIRST MEMBERS ............................................................................................................ 79 CHIP COST SHARING CAPS .................................................................................................................................................................... 80 CO-PAYMENT AND COST SHARING FOR CHIP PERINATAL MEMBERS ....................................................................................................... 80 BILLING CHIP MEMBERS ....................................................................................................................................................................... 80 MEMBER ACKNOWLEDGEMENT / PRIVATE PAY AGREEMENT/ ................................................................................................................... 80 FILING LIMITS ....................................................................................................................................................................................... 81 CLEAN CLAIM REQUIREMENTS ............................................................................................................................................................... 81 HOSPITAL FACILITY CLAIMS FOR PARKLAND CHIP PERINATE AND PARKLAND CHIP PERINATE NEWBORN .............................................. 86 FQHC/RHC REIMBURSEMENT .............................................................................................................................................................. 86 SPECIAL BILLING ................................................................................................................................................................................... 87 INPATIENT SERVICES BEFORE ENROLLMENT ........................................................................................................................................... 88 DISCHARGE AFTER DISENROLLMENT ...................................................................................................................................................... 88 CLAIMS APPEALS ................................................................................................................................................................................... 88 PROOF OF TIMELY FILING ...................................................................................................................................................................... 89 CHIP MEMBER ENROLLMENT AND DISENROLLMENT......................................................................................................... 90 ENROLLMENT APPLICATION ................................................................................................................................................................... 90 ENROLLMENT PROCESS .......................................................................................................................................................................... 90 RE-ENROLLMENT ................................................................................................................................................................................... 90 DISENROLLMENT ................................................................................................................................................................................... 91 PLAN CHANGES ..................................................................................................................................................................................... 91 CHIP PERINATAL MEMBER ENROLLMENT AND DISENROLLMENT ................................................................................ 91 ENROLLMENT......................................................................................................................................................................................... 91 NEWBORN PROCESS ............................................................................................................................................................................... 91 DISENROLLMENT ................................................................................................................................................................................... 92 PLAN CHANGES ..................................................................................................................................................................................... 92 PROVIDER MARKETING GUIDELINES ........................................................................................................................................ 92 CHIP PROVIDER MARKETING POLICY .................................................................................................................................................... 92 PATIENT EDUCATION PROCEDURES ........................................................................................................................................................ 93 FREQUENTLY ASKED QUESTIONS ABOUT THE MARKETING GUIDELINES ................................................................................................... 93 PROVIDER PARTICIPATION REQUIREMENTS ......................................................................................................................... 94 CREDENTIALING OF PHYSICIANS AND LICENSED INDEPENDENT PRACTITIONERS ...................................................................................... 94 RECREDENTIALING ................................................................................................................................................................................. 95 ORGANIZATIONAL PROVIDERS ................................................................................................................................................................ 95 REFERRALS ......................................................................................................................................................................................... 96 IN-NETWORK REFERRALS ....................................................................................................................................................................... 96 DIRECT ACCESS SERVICES ...................................................................................................................................................................... 96 REFERRALS TO ANCILLARY SERVICES ...................................................................................................................................................... 96 PRIOR AUTHORIZATION ................................................................................................................................................................. 97 NOTIFICATION REGARDING NEWBORN AND SONOGRAM PROCESS .............................................................................................................. 97 CLAIMS FOR OBSTETRIC DELIVERIES TO REQUIRE A MODIFIER ............................................................................................................... 97 TRANSPLANTS ...................................................................................................................................................................................... 102 PHYSICIAN OBLIGATIONS FOR HOSPITAL ADMISSIONS ........................................................................................................................... 102 ELECTIVE ADMISSIONS ......................................................................................................................................................................... 102 FACILITY OBLIGATIONS FOR ADMISSION ............................................................................................................................................... 103 ADMISSION TO OUT-OF-NETWORK FACILITIES ..................................................................................................................................... 103 CONCURRENT REVIEW ......................................................................................................................................................................... 103 DURABLE MEDICAL EQUIPMENT .............................................................................................................................................. 104 CARE FOR PERSONS WITH DISABILITIES, CHRONIC OR COMPLEX CONDITIONS ................................................... 104 iv
Page 1 and 2: Parkland KIDSfirst, Parkland CHIP P
Page 3: Notification of Change in Provider
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 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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