PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Reporting Member and Provider Fraud and Abuse to the OIG Once the detection is made, the SIU Coordinator will investigate the case to include any supporting elements needed to complete this investigation and will convene the Fraud and Abuse Committee to review. Upon recommendation of the Committee, the SIU Coordinator will review the case for completeness and accuracy and will be accountable for reporting all information to the OIG within fifteen (15) working days of making the determination on the fraud or abuse case via the HHSC-OIG fraud referral form. Expedited Referrals All cases involving the following situations will start an expedited referral to the OIG. 69 • Suspected harm or death to patients • Loss, destruction, or alteration of valuable evidence • Monetary loss • Hindrance of investigation or criminal prosecution of alleged offense Member, Provider, and Staff Education Members are urged to report suspected fraud and abuse through the Fraud and Abuse line. The Member Handbook, provided to members upon enrollment, is the primary communication vehicle for members of PCHP’s fraud and abuse plan. Periodic articles on fraud and abuse are also published in member newsletters. During orientations, the Provider Relations staff provides an overview of the fraud and abuse plan to newly contracted providers identifying their responsibility to report all cases of suspected fraud or abuse. Periodic articles regarding fraud and abuse are also published in the provider newsletters. Yearly mandatory fraud and abuse training is provided to all PCHP staff. The training incorporates the fraud and abuse plan, detailed information about the function of the SIU, detection of fraud and abuse, investigation procedures, and responsibility to reporting all suspected cases to the SIU. PCHP offers an online fraud awareness training tool that will help the staff to understand the obligations concerning detection and prevention of health care fraud and to instruct proper handling of transactions once health care fraud is suspected. Examples of member fraud or abuse including ID card fraud, ER abuse, and prescription drug abuse, are illustrated. Examples of provider fraud such as up-coding, billing for services not provided, and submitting false encounter data are also presented. If you suspect a person who receives benefits or a provider (a doctor, dentist, counselor, etc.) has committed waste, abuse, or fraud, you have a responsibility and a right to report it. Reporting Waste, Abuse or Fraud by a Provider or Client • You can report directly to your health plan any providers or clients you suspect of waste, abuse or fraud: Parkland Community Health Plan Attention: SIU Coordinator PO Box 569005 Dallas, TX 75356-9005 Call us telephonically using the toll free numbers in the Quick Reference Section of this manual. • Or if you can get on the Internet, go to www.hhs.state.tx.us and select the “Reporting Waste, Abuse, and Fraud” tab on the left side of the screen. The site informs you about the types of waste, abuse and fraud to report. If you cannot get on the Internet and you would rather talk to a person, call the HHSC Office of Inspector General Fraud Hotline at 1-800-436-6184, or you can send a note or letter to the following addresses:
70 To report providers use this address: To report clients use this address: Office of Inspector General Office of Inspector General Medicaid Provider Integrity/Mail Code 1361 General Investigations/ Mail Code1362 PO Box 85200 PO Box 85200 Austin, TX 78708-5200 Austin, TX 78708-5200 To report waste, abuse or fraud, gather as much information as possible • When reporting a provider (a doctor, dentist, counselor, etc.) include: o Name, address, and phone number of provider; o Name and address of the facility (hospital, nursing home, home health agency, etc.); o Medicaid number of the provider and facility, if you have it o Type of provider (doctor, dentist, therapist, pharmacist, etc.); o Names and phone numbers of other witnesses who can help in the investigation o Dates of events o Summary of what happened • When reporting about someone who receives benefits include: o The person’s name o The person’s date of birth, social security number, or case number if you have it o The city where the person lives o Specific details about the waste, abuse, or fraud. HHSC Regulatory Requirements for Fraud and Abuse PCHP network providers agree to offer the following entities or their designees with prompt, reasonable and adequate access to the network provider agreement and any records, books, documents, and papers that are related to the network provider agreement and/or the network provider’s performance of its responsibilities under this contract: 1. HHSC and MCO Program personnel from HHSC; 2. U.S. Department of Health and Human Services; 3. Office of Inspector General and/or the Texas Medicaid Fraud Control Unit; 4. An independent verification and validation contractor or quality assurance contractor acting on behalf of HHSC; 5. State or federal law enforcement agency; 6. Special or general investigation committee of the Texas Legislature; and 7. Any other state or federal entity identified by HHSC, or any other entity engaged by HHSC.
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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
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Covered Benefit CHIP Perinate Newbo
Page 26 and 27: Covered Benefit CHIP Perinate Newbo
Page 28 and 29: 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 and 74: your income. Co-payments do not app
Page 75: Member’s Right to Designate an OB
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
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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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