PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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If the complaint is received verbally, PCHP will send a verbal complaint form documenting the verbal complaint. Once the Provider has reviewed and agrees with this documentation, the provider will return the verbal complaint form to PCHP. PCHP must receive the written complaint for the resolution process to continue. Within five (5) business days of receipt of a complaint by a provider, PCHP will send written acknowledgement of receipt of the complaint. This acknowledgement letter will indicate a description of the complaint process and the thirty (30) calendar day time frame for resolution of the complaint. Once the complaint has been resolved, PCHP will send a response letter to the provider with the resolution of the complaint, including the process to appeal the complaint when the provider is not satisfied with the PCHP decision. Provider Appeal Process to HMO In the event that the complaint is not resolved to the satisfaction of the provider, the provider can ask for an appeal to the address noted. - If the appeal is received verbally, PCHP will send a verbal appeal form documenting the verbal appeal. Once the provider has reviewed and agrees with this documentation, the provider will return the verbal complaint/appeal form to PCHP for processing. “If the form is not returned by the Provider, Parkland will continue to research to resolve the complaint PCHP will send a written acknowledgement letter within five (5) business days of receipt of the written request for an appeal of the complaint decision. This acknowledgement letter will indicate that PCHP has thirty (30) calendar days to process and respond to the appeal. PCHP will send a resolution letter indicating the final determination and criteria used to reach the final decision and notice of the provider’s right to file a complaint with the Texas Department of Insurance (TDI). Provider Complaint Process to the State A provider who believes that they did not receive full due process from PCHP can file a complaint with TDI by calling toll free 1-800-252-3439 or in writing at: 53 Texas Department of Insurance PO Box 149104 Austin, Texas 78714-9104 The network provider understands and agrees that HHSC reserves the right and retains the authority to make reasonable inquiry and to conduct investigations into provider and member complaints. CHIP Member Complaints/Appeal Process Member 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 member.
A member or a member’s designee can file a complaint with PCHP either in writing or verbally by contacting the Member Advocate at: Parkland Community Health Plan Attention: Member Advocate PO Box 569005 Dallas, TX 75356-9005 Call us by phone using the number on page 1 of this manual or by calling 214-932-4564. If the complaint is received verbally, the Member Advocate will send a verbal complaint form documenting the verbal complaint. Once the member or member’s designee has reviewed and agrees with this documentation of the verbal complaint, the member or member’s designee must return the verbal complaint form to the Member Advocate for the resolution process to continue. Within five (5) business days of receipt of a complaint by a member or member’s designee, the Member Advocate will send written acknowledgement of receipt of the complaint. This acknowledgement letter will indicate a description of the complaint process and the thirty (30) calendar day time frame for resolution of the complaint. Investigation and resolution of complaints concerning emergencies or denials of continued stays for hospitalization will be concluded in accordance with the medical immediacy of the case, but can not exceed one (1) business day from receipt of the complaint. Once the complaint has been resolved, the Member Advocate will send a response letter to the member or member’s designee with the resolution of the complaint, including the process to appeal the complaint when the member or member’s designee is not satisfied with PCHP’s decision. Member Complaint Appeal Process to HMO In the event that the complaint is not resolved to the satisfaction of the member or member’s designee he/she can ask for an appeal through the Member Advocate at the address noted above. All appeals must be received within thirty (30) days from the date of the response letter to a complaint. If the appeal is received verbally, the Member Advocate will send a verbal complaint/appeal form documenting the verbal appeal. Once the member or member’s designee has reviewed and agrees with this documentation of the verbal appeal, the member or member’s designee will return the verbal complaint/appeal form to the Member Advocate for processing. All oral appeals received must be confirmed by a written, signed appeal by the member or member’s designee, unless an expedited appeal is requested. The Member Advocate will send a written acknowledgement letter within five (5) business days of receipt of the written appeal. This acknowledgement letter will indicate that the Member Advocate has thirty (30) days to process and respond to the appeal. The appeal will then be prepared for review by the Appeal Committee. Within five (5) calendar days following the Appeal Committee meeting or sooner, the Member Advocate will submit an Appeal Response letter to the member or member’s designee with the final decision of the appeal. Member Expedited Appeal Process to HMO The member or member’s designee can ask for an expedited appeal if he/she believes that taking the time for the standard appeal process could seriously jeopardize the life or health of the member. Requests for an 54
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Parkland KIDSfirst, Parkland CHIP P
Page 3 and 4:
Notification of Change in Provider
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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 58 and 59: Presentation at Emergency Room afte
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
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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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