PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Coordination with Texas Department of Family and Protective Services (TDFPS) Children who are served by TDFPS can transition into and out PCHP more rapidly and unpredictably than the general population, as a result of placements or reunification with the family inside and outside the Dallas Service Area. PCHP is required to cooperate and coordinate with the TDFPS and foster parents for the care of a child who is receiving services from or has been placed in the conservatorship of TDFPS. Should a request be made, PCHP will require its providers to: 1. Provide medical records. 2. Schedule medical and behavioral health appointments within 14 days, unless requested earlier by TDFPS. 3. Upon recognition of abuse and neglect, make the appropriate referral to TDFPS by calling toll free at 1-800- 252-5400 or by using the TDFPS secure website at www.txabusehotline.org. PCHP works with the TDFPS to ensure that at-risk children receive the services they need, whether or not they are in the custody of TDFPS. Providers must: • Refer suspected cases of abuse or neglect to TDFPS. • Provide periodic written updates on treatment status of members, as required by TDFPS. • Contact TDFPS for assistance with members. Hospital Transfers Discharge from one hospital and readmission or admission to another hospital within 24 hours for continued treatment shall not be considered a discharge but rather a hospital transfer. Compliance with PCHP Policy and Procedures Providers will meet the Plan guidelines including updated changes, benefits, limitations to program, etc. with all policies and procedures implemented by PCHP Utilization Management and Quality Improvement Programs. Pharmacy Benefits PCHP covers prescription medications. Prescription drugs must be ordered by a licensed prescriber within the scope of the prescriber’s practice. Prescriptions should be written to allow generic substitution whenever possible and signatures on prescriptions must be legible in order for the prescription to be dispensed. Providers are responsible for ensuring that members receive all medications for which they are eligible. Our members can get their prescriptions for the CHIP copay when: 49 • They get their prescriptions filled at a network pharmacy It is important that you as the provider know about other prescriptions your patient is already taking. Also, ask them about non-prescription medicine or vitamin or herbal supplements they may be taking. CHIP members are eligible to receive an unlimited number of prescriptions per month and may receive up to a 90-day supply of the drug. Vision Services
Parkland KidsFirst and Parkland CHIP Perinate Newborn members are eligible for an eye examination to determine the need for and prescription of corrective lenses per 12 month-period through Block Vision, without authorization or referral. Additional eye health care services provided by an in-network Optometrist or Ophthalmologist (other than surgery) can be provided without a referral from the member’s Primary Care Provider. Covered surgical/laser care requires prior-authorization. Routine, Urgent, and Emergency Services Routine Care “Routine Services” are defined as covered preventive and medically necessary health care services, which are non-emergent or non-urgent. These types of services should be performed by the member’s Primary Care Provider. PCHP will only approve emergency transportation cost for true emergencies. Urgent Care An “urgent” condition is defined as a health condition which is not an emergency but is severe or painful enough to cause a prudent layperson possessing the average knowledge of medicine to believe that his or her condition requires medical evaluation or treatment within 24 hours to prevent serious deterioration to his or her condition or health. The member might need urgent medical care while away from home. If so, the member should call the primary provider (Primary Care Provider or CHIP Perinatal provider) before seeking medical care. It is the primary provider’s responsibility to decide if the member needs any medical care services before returning home. If the member does need urgent care, the primary provider will approve the care. Certain conditions, such as severe vomiting, earaches, sore throats or fever are considered “urgent” outside the PCHP service areas and are covered in any of the above settings. Preventive care services and other routine treatment for conditions such as minor colds and flu are not covered outside the PCHP service areas. Emergency Care Emergency care is a covered service. Emergency care is a covered Parkland CHIP Perinate service as related to the unborn child. “Emergency” and “emergency condition” means a medical condition of recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the condition, sickness, or injury is of such a nature that failure to get immediate care could result in: • placing the child’s or unborn child’s health in serious jeopardy; • serious impairment to bodily functions or the child or as related to the unborn child; • serious dysfunction of any bodily organ or part of the child or that would effect the unborn child; • serious disfigurement of the child or the unborn child; or • in the case of a pregnant Parkland KIDSfirst member, serious jeopardy to the health of the fetus. “Emergency services” and “emergency care” means health care services offered in an in-network or out-ofnetwork hospital emergency department or other comparable facility by in-network or out-of network doctors, providers, or facility staff to evaluate and stabilize medical conditions. Emergency services also include, but are not limited to any medical screening examination or other evaluation required by state or federal law that is necessary to find out whether an emergency condition related to the Parkland KIDSfirst, Parkland CHIP Perinate Newborn member, or Parkland CHIP Perinate unborn child exists. 50
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 54 and 55: Coordination of Care The Primary Ca
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
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provider actually treating the memb
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themselves appropriately and follow
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Medical Record Standards The medica
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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
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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
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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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