PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

More documents

Recommendations

Info

Extra Benefits • Parkland Nurse Line 24 Hours a Day, 7 Days a Week – a 24 hour Nurse Help Line to help with health questions or to help members decide what to do about their child’s health needs. • Free Health Education Classes - Parkland CHIP Perinate has classes for parents and children on many different health subjects. Small gifts are provided to members who attend the special health education programs Some of the classes are related to: - Prenatal care (free at Parkland Health and Hospital System) - Child safety - Parenting skills - Getting ready for baby - Asthma, pediatric diabetes, etc. 65 (Note: some limitations apply.) • Continued Access to Care through a network of health care providers participating with Parkland HEALTHplus if CHIP Perinate eligibility is lost. Member Rights and Responsibilities Member Rights 1. You have a right to get accurate, easy-to-understand information to help you make good choices about your child’s health plan, doctors, hospitals and other providers. 2. Your health plan must inform you if they use “limited” provider network.” This is a group of doctors and other providers who only refer to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses “limited networks,” you should check to see that your child’s primary care provider and any specialist doctor you might like to see are part of the same “limited network.” 3. You have a right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know about what those payments are and how they work. 4. You have a right to know how the health plan decides about whether a service is covered and/or medically necessary. You have the right to know about the people in the health plan who decides those things. 5. You have a right to know the names of the hospitals and other providers in your health plan and their addresses. 6. You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it. 7. If your doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child’s primary care provider. Ask your health plan about this. 8. Children who are diagnosed with special health care needs or a disability have the right to special care. 9. If your child has special medical problems, and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months and the health plan must continue paying for those services. Ask your plan about how this works. 10. Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her primary care provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral. 11. Your child has the right to emergency services if you reasonably believe your child’s life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a co-payment depending on
your income. Co-payments do not apply to CHIP Perinatal. 12. You have the right and responsibility to take part in all the choices about your child’s health care. 13. You have the right to speak for your child in all treatment choices. 14. You have the right to get a second opinion from another doctor in your health plan about what kind of treatment your child needs. 15. You have the right to be treated fairly by your health plan, doctors, hospitals and other providers. 16. You have the right to talk to your child’s doctors and other providers in private, and to have your child’s medical records kept private. You have the right to look over and copy your child’s medical records and to ask for changes to those records. 17. You have the right to a fair and quick process for solving problems with your health plan and the plan’s doctors, hospitals and others who provide services to your child. If your health plan says it will not pay for a covered service or benefit that your child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, inform you if they think your doctor or the health plan was right. 18. You have a right to know that doctors, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. 19. You have the right to know that you are responsible for paying allowable copayments for covered services. Doctors, hospitals, and others cannot require you to pay any other amounts for covered service. Member Responsibilities You and your health plan both have an interest in seeing your child’s health improve. You can help by assuming these responsibilities. 1. You must try to follow healthy habits. Encourage your child to stay away from tobacco and to eat a healthy diet. 2. You must become involved in the doctor’s decisions about your child’s treatments. 3. You must work together with your health plan’s doctors and other providers to pick treatments for your child that you have all agreed upon. 4. If you have a disagreement with your health plan, you must try first to resolve it using the health plan’s complaint process. 5. You must learn about what your health plan does and does not cover. Read your Member Handbook to understand how the rules work. 6. If you make an appointment for your child, try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and cancel it. 7. If your child has CHIP, you are responsible for paying your doctor and other provider co-payments that you owe them. If your child is getting CHIP Perinatal services, you will not have co-payments for that child. 8. You must report misuse of the CHIP or CHIP Perinatal services by health care providers, other members, or health plans. 66
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 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: Pregnant Teens Please call Parkland
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?