PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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• Information concerning the grievances and appeals process Reminder notices are sent 14 days after enrollment packages are mailed to members. Concurrent notice is sent to the Community Based Organization (CBO) when there is a record of past involvement with the family. A follow-up letter is mailed 14 days after the reminder notices. Families who are unresponsive to the two followup attempts are timed out after 60 days. Post-enrollment letters are sent as temporary evidence of coverage, pending receipt of the health plan ID card. Enrollment letters will contain the following information: • Member ID numbers • First date of coverage • Health plan and Primary Care Provider sections • Applicable co-payments Re-Enrollment At the beginning of the tenth month of coverage, the Administrative Services Contractor will send a notice to the family outlining the next steps for renewal for continuation of coverage. The Administrative Services Contractor will also send a notice to the Health Plan regarding its members and to a community based outreach organization providing follow-up assistance in the members’ areas. To promote continuity of care for children eligible for re-enrollment, the HMO can ease re-enrollment through reminders to members and other appropriate means. Failure of the family to respond to the Administrative Services Contractor’s renewal notices will result in disenrollment from the plan and from CHIP. Disenrollment For those members who are disenrolled because they are no longer eligible for CHIP, the HMO will receive from the Administrative Services Contractor notice informing the HMO that the members’ coverage will end on a particular date. Disenrollment due to loss of eligibility includes, but is not limited to; “aging-out” when a child turns 19, failure to re-enroll at the conclusion of the 12-month eligibility period, change in health insurance status, failure to meet monthly cost–sharing obligation, death of the child, child permanently moves out of the state, and data match with the Medicaid system indicates dual enrollment in Medicaid and CHIP. PCHP has a limited right to ask for a member be disenrolled from the Plan without the member’s consent. PCHP’s request to disenroll a member from the Plan will require medical documentation from the member’s Primary Care Provider or documentation that indicates sufficiently compelling circumstances that merits disenrollment. HHSC must approve and will make the final decision on any request by PCHP for disenrollment of a member for cause. • We will take reasonable measures to correct a member’s behavior before asking for disenrollment. Reasonable measures can include providing education and counseling regarding the offensive acts or behaviors. • If all reasonable measures fail to remedy the problem, PCHP will inform the member of the decision to recommend disenrollment to HHSC. • We cannot ask for a disenrollment based on adverse change in the member’s health status or utilization of services that are medically necessary for treatment of a member’s condition. • Additionally, a provider cannot take retaliatory action against a member who is disenrolled from PCHP. 59
Plan Changes Members are only allowed to make plan changes once a year. Members can ask to change health plans for exceptional reasons or good cause. HHSC must approve and will make the final decision on any request by members to change health plans. CHIP Perinatal Member Enrollment and Disenrollment Enrollment The mother of the CHIP Perinate has 15 calendar days from the time the enrollment packet is sent by the vendor to enroll in an MCO (where choice is available). Newborn Process 60 • All CHIP and CHIP Perinatal members in a household must be enrolled in the same MCO. Upon certification of CHIP Perinatal eligibility, children in the same household enrolled in the CHIP must be prospectively enrolled in the MCO providing the CHIP Perinatal coverage and disenrolled from their current MCO the first possible month. Co-payments, cost-sharing and enrollment fees still apply to children enrolled in CHIP. • In order to synchronize all CHIP and CHIP Perinatal members in a household, all members will remain in the MCO providing CHIP Perinatal coverage until the CHIP Perinate Newborn completes its 12- month eligibility. After the CHIP Perinate Newborn’s coverage period is completed, the child will be added to the existing CHIP case. The coverage period for the newly enrolled child will be the remaining period of coverage of the siblings already enrolled in the CHIP. Plan Changes • Once the mother of the CHIP Perinate picks an MCO, the CHIP Perinate must remain in this MCO until the end of the CHIP Perinatal continuous eligibility period. • If the mother of the CHIP Perinate does not pick an MCO within 15 calendar days of receiving the enrollment packet, the CHIP Perinate is defaulted into an MCO and the mother is notified of the plan choice. When this happens, the mother has 30 days to pick another MCO. • All CHIP and CHIP Perinatal members must remain in the same MCO until the end of the CHIP Perinatal continuous eligibility period. After the CHIP Perinate Newborn’s coverage period is completed, the child will be added to the existing CHIP case. The coverage period for the newly enrolled child will be the remaining period of coverage of the siblings already enrolled in CHIP. At the first CHIP renewal after the CHIP Perinatal eligibility ends, the family can pick a new MCO. Note: The switch of CHIP members from their MCO to the MCO providing the CHIP Perinatal coverage does not count as their one MCO change per year. • Members can ask to change MCOs for exceptional reasons or good cause. Disenrollment HHSC must approve and will make the final decision on any request for disenrollment of a member for cause. A provider cannot take retaliatory action against a member who is disenrolled from PCHP CHIP Perinate or PCHP CHIP Perinate Newborn.
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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
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Plan specified services. However, c
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CHIP Covered Services PCHP provides
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• 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 62 and 63: Expedited Appeal can be made verbal
Page 64 and 65: CHIP Eligibility CHIP KidsFirst Mem
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
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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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