PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Presentation at Emergency Room after Hours If a PCHP member presents for care at an Emergency Room after normal business hours, covered services will not be denied. The Emergency Room staff should inform the member’s health plan and the member’s primary provider (Primary Care Provider or CHIP Perinatal provider) no later than the next business day. All follow-up care should be referred to the member’s primary provider. Note: Parkland CHIP Perinate members have limited benefits. Please refer to the CHIP Perinate Covered Services section of this manual for details on covered and excluded emergency and outpatient services. Presentation at Emergency Room during Normal Business Hours If a PCHP member presents for care at an Emergency Room during normal business hours, the Emergency Room staff should contact the member’s primary provider (Primary Care Provider or CHIP Perinatal provider) and await the primary provider’s recommendation (e.g., come to office, be seen at ER, etc.), unless the patient’s condition is emergent. Should the primary provider direct that care be rendered at the ER, the staff should document the primary provider’s instructions in the member’s medical record and proceed accordingly. All follow-up care should be referred to the member’s primary provider. Note: Parkland CHIP Perinate members have limited benefits. Please refer to the CHIP Perinate Covered Services section of this manual for details on covered and excluded emergency and outpatient services. Emergency Services and Care If member needs immediate treatment, proceed and treat. Within 24 hours of an emergency admission or an emergency room visit, the provider must notify PCHP and the Primary Care Provider with the following information: • Member’s full name • Member ID number • Diagnosis for emergency admission • Facility where member was admitted • Admitting physician name Emergency Admission The member’s primary provider (Primary Care Provider or CHIP Perinatal provider) or the admitting Emergency Room must call Parkland PCHP’s Patient Management Department at 1-888-814-2352 to inform the health plan of any emergency hospital admission for a PCHP member. PCHP must be notified within one (1) business day. Emergency Ambulance Services When the PCHP member’s condition is life-threatening, and trained attendants must use special equipment, life support systems, or close monitoring while en-route to the nearest appropriate facility, the ambulance transport is deemed an emergency service. Non-Emergency Ambulance Service When a PCHP member has a medical problem requiring treatment in another location and is so severely disabled that the use of an ambulance is the only appropriate means of transfer, the ambulance service must be approved and coordinated by PCHP. Non-emergency transport service for a CHIP member with severe disabilities must be to or from a scheduled medical appointment. Non-emergency ambulance services are not a benefit for the Parkland CHIP Perinate member. 51
Emergency Prescription Supply A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization is not available. This applies to non-preferred drugs on the Preferred Drug List and any drug that is affected by a clinical or prior authorization edit and would need prescriber prior approval. Definition of Emergency Transportation When the Member’s condition is life-threatening and trained attendants must use special equipment, life support systems or close monitoring while en route to the nearest appropriate facility, the ambulance transport is deemed an emergency service. Non-Emergency Medical Transportation PCHP is committed to identifying members with transportation needs and coordinating services with the Department of State Health Services (DSHS) Medical Transportation Program (MTP) and other community based transportation programs. Providers and their staff will be encouraged to help members identify and address their transportation needs. The availability of these services will be discussed during your Provider Orientation. CHIP Emergency Dental Services: PCHP is responsible for emergency dental services provided to CHIP Members and CHIP Perinate Newborn Members in a hospital or ambulatory surgical center setting. We will pay for hospital, physician, and related medical services (e.g. anesthesia and drugs) for: • Treatment of dislocated jaw, traumatic damage to teeth, and removal of cysts; • Treatment of oral abscess of tooth or gum origin; and • Treatment craniofacial anomalies. Provider Complaints and Appeals Process Provider Complaints to HMO Definition of a “Complaint” – Any dissatisfaction expressed by a Complainant, orally or in writing to PCHP, with any aspect of Parkland Community Health Plan’s operations, including, but not limited to, dissatisfaction with plan administration, procedure related to review or Appeal of an Adverse Determination, as defined in Texas Insurance Code, Chapter 843, Subchapter G; the denial, reduction, or termination of a service for reasons not related to medical necessity; the way a service is provided; or disenrollment decisions. A complaint is not related to misinformation that is resolved promptly by supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the PCHP provider. Providers can file a complaint either in writing or verbally by contacting: Parkland Community Health Plan Provider Relations Department PO Box 569005 Dallas, TX 75356-9005 1-888-672-2277 Parkland Community Health Plan will make resources available to help providers in filing a complaint. 52
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 56 and 57: Coordination with Texas Department
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
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RATIONALE: Prevention of RSV Illnes
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RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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