PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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<strong>Parkland</strong> CHIP Perinate 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 unborn child’s health plan, doctors, hospitals and other providers. 2. You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work. 3. You have a right to know how the health plan decides whether a Perinatal service is covered and/or medically necessary. You have the right to know about the people in the health plan who decides those things. 4. You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses. 5. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed. 6. You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan. 7. You have the right and responsibility to take part in all the choices about your unborn child’s health care. 8. You have the right to speak for your unborn child in all treatment choices. 9. You have the right to be treated fairly by the health plan, doctors, hospitals and other providers. 10. You have the right to talk to you Perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records. 11. You have the right to a fair and quick process for solving problems with the health plan and the plan's doctors, hospitals and others who provide perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn 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. Member Responsibilities You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities. 1. You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet. 2. You must become involved in the doctor's decisions about your unborn child’s care. 3. If you have a disagreement with the health plan, try first to resolve it using the health plan's complaint process. 4. You must learn about what your health plan does and does not cover. Read your CHIP Perinatal Handbook to understand how the rules work. 5. You must try to get to the doctor's office on time. If you cannot keep the appointment, be sure to call and cancel it. 6. You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans. 67
Member’s Right to Designate an OB/GYN Female members have the right to select an OB/GYN without a referral from their Primary Care Provider. The access to health care services of an OB/GYN includes: • One well-woman checkup per year • Care related to pregnancy • Care for any female medical condition • Referral to special doctor within the network PCHP limits the selection of an Ob/Gyn to its Primary Care Provider network. Pregnant members past the 24 th week of pregnancy must be allowed to remain under the care of their current Ob/Gyn or select an Ob/Gyn within the network if she chooses to do so, and if the provider to whom she wants to change agrees to accept her. Fraud Reporting Fraud and Abuse PCHP proposes an aggressive, proactive fraud and abuse program that complies with state and federal regulations. Our program targets areas of health-care related fraud and abuse including internal fraud, electronic data processing fraud and external fraud. A Special Investigations Unit (SIU) will be a key element of the program. This SIU will find, investigate and report any suspected or confirmed cases of fraud, abuse or waste to the Office of Inspector General (OIG). During the investigation process, the confidentiality of the patient and or people referring the potential fraud and abuse case is maintained. PCHP will use a variety of mechanisms to find potential fraud or abuse. All key functions including Claims, Provider Relations, Member Services, Patient Management, as well as providers and members, will share the responsibility to find and report fraud. Review mechanisms will include audits, review of provider service patterns, hotline reporting, claim review, data validation and data analysis. Investigation of Fraud/Abuse The SIU Coordinator will conduct a preliminary investigation within fifteen (15) working days of identification of a potential fraud or abuse case. This investigation will include information from previous investigations; a review of Provider Relations educational/visitation logs, provider profile reports, individual provider paid or denied claims and encounter reporting. The SIU Coordinator will also review the provider’s prior payment history. Medical Record Review After the first investigation is conducted and it has been found that possible fraud exists, a sample of fifty (50) members or fifteen (15) percent of the provider’s claims will be requested within fifteen (15) days of making the determination. Within fifteen (15) days of picking the sample, the SIU Coordinator will request medical records and encounter data from the provider or member in question and review the medical records and encounter data within forty-five (45) days of receipt, to validate the sufficiency of data and ensure accuracy of encounter data. An evaluation of the need to review any additional medical records will also be assessed. 68
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
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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
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Outpatient Mental Health Services I
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• Out-of-network services not aut
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CHIP Perinatal Covered Services Cov
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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 and 72: Pregnant Teens Please call Parkland
Page 73: your income. Co-payments do not app
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
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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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