PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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.
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