PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

More documents

Recommendations

Info

Expedited Appeal can be made verbally or in writing as indicated in the Member Complaint to HMO listed above. Expedited appeals for emergency care denials and denials of continued hospital stays will be reviewed by a Medical Director that was not involved in the original denial and is of the same or a similar specialty as typically manages the medical condition, procedure, or treatment under review. The time frame in which the appeal is completed will be based on the medical immediacy of the condition, procedure, or treatment, but will not exceed one (1) working day from the date all information necessary to complete the appeal is received. If the member or member’s designee asks for an expedited appeal for a denial that does not involve an emergency, an ongoing hospitalization or services that are already being given they will be notified that the appeal review cannot be expedited. We will continue to process the appeal within the standard timeframe and respond to you within 30 days from the time the appeal was received. If the member or member’s designee does not agree with this decision they can submit a request for an Independent Review Organization as described below. Members can also file a complaint to the Texas Department of Insurance by calling 1-800-252-3439 or writing to: Texas Department of Insurance PO Box 149104 Austin, TX 78714-9104 Fax: 512-475-1771 Web: http://www.tdi.state.tx.us Email: ConsumerProtection@tdi.state.tx.us Member Adverse Determination Appeal Process to HMO A member, a person acting on behalf of the member, or the member's doctor or health care provider can appeal an adverse determination orally or in writing. Any complaint filed concerning dissatisfaction or disagreement with an adverse determination constitutes an appeal of the adverse determination. Within five (5) working days from receipt of the appeal, an acknowledgement letter will be sent to the appealing party. The acknowledgement letter will include: the date of receipt of the appeal; a description of the appeal procedure and timeframes; a list of the documents, such as new, previously unknown information, further reasonable documentation related to the case but not previously received or medical records that will need to be submitted for review during the appeal process. The provider will have five (5) business days to submit the additional information requested; and a one-page appeal form, if the appeal is oral. As soon as practical, but in no case later than thirty (30) calendar days of receipt of the appeal, all available information will be reviewed by a doctor who was not involved in making the initial adverse determination and a written notice of the appeal determination will be sent to the appealing party. If the appeal is denied, the written notice to the member, member’s designee, and member’s provider shall include a clear and concise statement that includes: the clinical basis for the appeal’s denial; the specialty of the doctor making the denial; the right of the appealing party to seek review of the denial by an independent review organization and the procedures for obtaining that review; the right to an immediate appeal to an independent review organization in circumstances involving a condition that is life-threatening to the member; the right of the health care provider to set forth in writing within ten (10) working days of the appeal denial good cause for having a particular type of specialty provider review the case. 55
Independent Review Organization (IRO) Process The member or member’s designee may seek a review of PCHP’s denial of an appeal of an adverse determination by an independent review organization assigned to the appeal in accordance with TIC Article 21.58C. The member or member’s designee must complete the “Request for IRO Review” form and return to PCHP within fifteen (15) days from receipt of PCHP’s decision. An Independent Review Organization (IRO) is an organization that has no connection to PCHP or with health care providers that were previously involved in your treatment or decisions made by PCHP about services that have not been provided. Once PCHP receives the completed form, we will notify TDI of the member’s request for an IRO review. The standard time frame for the IRO process should take no longer than twenty (20) calendar days from the date the completed form and all necessary information is received by the IRO. If the member has an emergency health condition, the IRO process should take no longer than eight (8) calendar days from the date the completed form and all necessary information were received by the IRO. 56
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 58 and 59: Presentation at Emergency Room afte
Page 60 and 61: If the complaint is received 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
Page 117 and 118:
WIC services include providing nutr
Page 119 and 120:
As soon as the member knows they wi
Page 121 and 122:
3) by the director to the employee
Page 123 and 124:
In addition to the previously state
Page 125 and 126:
Prior Authorization The CHIP Perina
Page 127 and 128:
Appendix A Universal Referral/Prior
Page 129 and 130:
Appendix B Consent for Disclosure 1
Page 131 and 132:
PERMISSION TO RELEASE CONFIDENTIAL
Page 133 and 134:
EXAMPLE FORM PRIVATE PAY AGREEMENT
Page 135 and 136:
Appendix D Clinical Practice Guidel
Page 137 and 138:
Appendix D - Continued Clinical Pra
Page 139 and 140:
Appendix D - Continued Clinical Pra
Page 141 and 142:
RATIONALE: Attention-Deficit/ Hyper
Page 143 and 144:
Appendix G Urinary Tract Infections
Page 145 and 146:
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
show all

PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Create successful ePaper yourself

Delete template?

Save as template?