PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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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 47
Medical Director in order for coverage to be extended at the new Plan level. The PCHP Medical Management department will coordinate all necessary referrals, precertifications or any other authorizations so that the continuity of care is not disrupted. In order for a non-participating provider to continue treating members during a transition period, the provider must agree to: • Continue to provide the members’ treatment and follow-up. • Continue to accept Plan rates and/or fee schedules. • Continue to share information regarding the treatment plan with the Plan. • Continue to use the Plan network for any necessary referrals, lab work or hospitalizations. Any exceptions will be reviewed on a case-by-case basis by the Medical Management staff in consultation with the Medical Director. We will follow the established Prior Authorization timeframes. Medical Record Standards Medical records must reflect all aspects of patient care, including ancillary services. Participating providers and other health care professionals agree to maintain medical records in a current, detailed, organized and comprehensive manner in accordance with customary medical practice, applicable laws and accreditation standards. Medical records must reflect all aspects of patient care, including ancillary services. Detailed information on Medical Records Standards can be found later in this manual. Out-of-Network Referrals If a required service is not available within the PCHP contracted network, the member’s primary care provider can make an out-of-network referral. However, the Primary Care Provider must obtain authorization from PCHP Patient Management Department. Request for referrals to non-participating specialists require prior authorization. Coverage for the use of a non-participating provider is approved to ensure timely and adequate access to necessary care which is not otherwise available from a provider within the participating provider network. In making a determination, continuity of care issues for members with complex medical problems are considered when reviewing such requests. In general, these members require a unique, highly specialized service. When appropriate, the Primary Care Provider is informed of equally qualified alternative providers within the network or if such services become available from a network provider. The steps for an out-of-network referral are as follows: 1) The member’s Primary Care Provider must complete a referral request, and specify the services required of the out-of-network provider including the rationale for requesting out-of-network services. 2) The Primary Care Provider must fax the referral form and all pertinent clinical information to the PCHP Patient Management Department at 1-888-240-0410 to obtain approval. 3) An authorization number will be assigned by the PCHP Utilization Management Department. The out-of-network referral is valid for thirty (30) days for a maximum of two visits unless otherwise authorized by the Primary Care Provider. A new referral request must be completed if the referral is over thirty (30) days old or more than two visits are required unless additional visits have been authorized by the Primary Care Provider. 48
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 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 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
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WIC services include providing nutr
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As soon as the member knows they wi
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3) by the director to the employee
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In addition to the previously state
Page 125 and 126:
Prior Authorization The CHIP Perina
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Appendix A Universal Referral/Prior
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Appendix B Consent for Disclosure 1
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PERMISSION TO RELEASE CONFIDENTIAL
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EXAMPLE FORM PRIVATE PAY AGREEMENT
Page 135 and 136:
Appendix D Clinical Practice Guidel
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Appendix D - Continued Clinical Pra
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Appendix D - Continued Clinical Pra
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RATIONALE: Attention-Deficit/ Hyper
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Appendix G Urinary Tract Infections
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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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