PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Coordination of Care
The Primary Care Provider and participating specialists are expected to communicate often regarding the health
care services provided to each member. Copies of prior authorization and referral forms and other relevant
communication between the specialist and the Primary Care Provider should be maintained in both providers’
files for the member. Coordination of care is vital to assuring members receive appropriate and timely care as
well as communication between providers for members who have moved out of the service area and allows for
transferred care to a new HMO and provider. Compliance with this coordination is reviewed closely during site
visits for credentialing and recredentialing, as well as during quality improvement and utilization management
reviews.
Continuity of Care Pregnant Women
Pregnant members past the 24 th week of pregnancy will be allowed to remain under the care of their current
Obstetrician/Gynecologist or pick an Obstetrician/Gynecologist within the network if she chooses to do so, and
if the provider to whom she wants to change agrees to accept her.
Member Moves Out of Service Area
Members who move out of the service area are responsible for obtaining a copy of their medical records from
their current Primary Care Provider to provide to their new Primary Care Provider. Participating providers must
furnish members with copies of their medical records.
Pre-existing Conditions
PCHP does not have a pre-existing condition limitation. PCHP is responsible for providing all covered services
to each eligible member beginning on the member’s date of enrollment into PCHP, regardless of any preexisting
conditions, prior diagnosis and/or receipt of any prior health care.
Coverage will be authorized for care being provided by nonparticipating providers to members who are in an
“Active Course of Treatment” at the time of enrollment until the member’s records, clinical information and
care can be transferred to a network provider or until such time the member is no longer enrolled in the plan.
Coverage will be provided until the active course of treatment has been completed or 90 days, whichever is
shorter. Out-of-network care will be coordinated for members who have been diagnosed and are receiving
treatment for a terminal illness at the time of enrollment for up to nine months or until no longer enrolled in the
plan.
“Active Course of Treatment” is defined as:
• A planned program of services rendered by a physician, behavioral health provider or DME provider.
• Starts on the date a provider first renders a service to correct or treat the diagnosed condition.
• Covers a defined number of services or period of treatment.
• A pregnant woman to remain under the member’s current Ob/Gyn care though the member’s post-partum
checkup even if the Ob/Gyn provider is, or becomes, out-of-network.
In order to provide transitional coverage for the nonparticipating provider, the following conditions must be
met. The member must:
• Be enrolling as a new member, and receiving ongoing treatment for a chronic or acute medical condition
from a nonparticipating provider.
• Have initiated an “Active Course of Treatment” prior to the initial enrollment date.
If services are received prior to the approval of transition of benefits, the services must be approved by the
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