PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

y the specialist. Services performed in a specialist’s office that are integral to the evaluation of the problem
that led to the referral to the specialist are included in the scope of the referral and will be reimbursed according
to the standard claim processing guidelines. It is the provider’s responsibility to verify the member’s eligibility
and benefits prior to rendering services. It is not necessary for providers to verify authorization for services that
are not included on the Prior Authorization List.
To encourage communication from the specialist to the Primary Care Provider, it is recommended that the
initial consultative referral be authorized for one visit. Following an initial consultation, the specialist should
communicate with the referring Primary Care Provider in a timely fashion to develop an appropriate course of
treatment (for example, referrals for additional services and/or follow-up care, if needed). It is recommended
that referrals for additional visits be for no more than three (3) visits and/or 90 days to ensure the Primary Care
Provider and specialist communicate frequently regarding the health services provided to each member.
Additional referrals may be required if the specialist:
• Wishes to provide additional services other than the outpatient laboratory or diagnostic imaging
• Refers the member to another specialist for services and procedures that are not included in the referral
• Requires additional visits or an extension of the timeframe authorized by the Primary Care Provider.
Coordination of care is vital to assuring Member’s receive appropriate and timely care. Relevant
communication between specialist and the Primary Care Provider should be maintained in both providers’ files
for the member. We monitor coordination of care as part of its ongoing quality and utilization management
reviews.
Prior authorization is required for certain specialty types (primarily those for which there are limited benefits)
and selected procedures. When prior authorization is required, the Primary Care Provider must submit the Texas
Referral/Authorization form and all pertinent clinical information that supports the medical necessity of the
requested services to the PCHP Prior Authorization unit for approval. The list of services requiring prior
authorization by PCHP is regularly updated and posted on www.parklandhmo.org.
Please refer to the Medical Management Section of this manual for information about the
PCP and Behavioral Health
Members seen in the primary care setting may present with a behavioral health condition, which the PCP must
be prepared to recognize. PCPs are encouraged to use behavioral health screening tools, treat behavioral health
issues that are within their scope of practice and refer Members to behavioral health providers when
appropriate.
Referral to Network Facilities and Contractors
We contract with the following providers to perform lab services for our members. Each lab will have various
draw sites and the Member is able to go the nearest draw site for services
Access to Second Opinion
PCHP must allow members access to a second opinion from a network provider or out-of-network provider if a
network provider is not available, at no additional cost to the member. Pregnant Members past the 24th week of
pregnancy must be allowed to remain under the care of their current Ob/Gyn. She may select an Ob/Gyn within
the network if she chooses to do so and if the provider to whom she wants to change agrees to accept her.
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