PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

More documents

Recommendations

Info

PCHP network providers must provide access wherever they maintain such records, books, documents and papers. The network provider must provide such access in reasonable comfort and provide any furnishings, equipment and other conveniences deemed reasonably necessary to fulfill the purposes described herein. Requests for access can be for, but are not limited to, the following purposes: 1. examination; 2. audit; 3. investigation; 4. contract administration; 5. the making of copies, excerpts, or transcripts; or 6. any other purpose HHSC deems necessary for contract enforcement or to perform its regulatory functions. PCHP Network Provider understands and agrees that the acceptance of funds under the Medicaid or CHIP contract acts as acceptance of the authority of the State Auditor’s Office (“SAO”), or any successor agency, to conduct an investigation in connection with those funds. PCHP providers further agree to cooperate fully with the SAO or its successor in the conduct of the audit or investigation, including providing all records requested. PCHP network provider understands and agrees to the following: 1. HHSC Office of Inspector General (“OIG”) and/or the Texas Medicaid Fraud Control Unit must be allowed to conduct private interviews of network providers and their employees, agents, contractors, and patients; 2. requests for information from such entities must be complied with, in the form and language requested; 3. Network providers and their employees, agents, and contractors must cooperate fully with such entities in making themselves available in person for interviews, consultation, grand jury proceedings, pre-trial conference, hearings, trials and in any other process, including investigations at the network provider’s own expense; and 4. Compliance with these requirements will be at the PCHP network provider’s own expense. PCHP network provider understands and agrees to the following: 1. Network providers are subject to all state and federal laws and regulations about fraud, abuse or waste in health care and Medicaid and/or CHIP, as applicable; 2. Network providers must cooperate and help HHSC and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste; 3. Network providers must provide originals and/or copies of any and all information, allow access to premises, and provide records to the Office of Inspector General, HHSC, the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services, FBI, TDI, the Texas Attorney General’s Medicaid Fraud Control Unit or other unit of state or federal government, upon request, and free-of-charge; 4. If the network provider places required records in another legal entity's records, such as a hospital, the network provider is responsible for obtaining a copy of these records for use by the above-named entities or their representatives; and 71
5. Network providers must report any suspected fraud or abuse including any suspected fraud and abuse committed by the MCO or a Member to the HHSC Office of Inspector General. State and Federal False Claims Acts and Whistleblower Protections Parkland Community Health Plan (PCHP) is also responsible for investigating and reporting fraud or abuse related to the filing of false claims against the United States Government or failure of an MCO to provide services required under contract with the state of Texas, enrollment/marketing violations or wrongful denials of claims. This information is detailed in the following locations: • Title 31 United States Code (USC), Subtitle III, Chapter 37, Subchapter III, Section 3729 – 3733 (Federal False Claims Act). • Title 31 United States Code (USC), Chapter 38 (Administrative Remedies) • Texas Human Resources Code Chapter 32, Subchapter B, Section 32.039 (Texas False Claims Act • Texas Human Resources Code Chapters 32 and 36 (Administrative and Civil Remedies) Parkland Community Health Plan staff, contracted providers, entities or agents are protected from retaliation from PCHP in the event that they report suspected filing of false or fraudulent claims against the Government by Parkland Community Health Plan. In 1986, congress added anti-retaliation protections to the False claims Act. These Provisions are contained in 31 USC Section 3730(h) and state that: 72 Any employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer because of lawful acts done by the employee on behalf of his employer or others in furtherance of and action under this section, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under this section, shall be entitled to all relief necessary to make the employee whole. Additional information on the False Claims Acts and Whistleblower Protections can be found in the Parkland Community Health Plan Fraud and Abuse Plan on the PCHP website (www.parklandhmo.org) or in the federal and state statute listed above. You can also contact PCHP Provider Relations for further information. Specialist Responsibilities Care by specialists will be provided after a referral has been made by the member’s Primary Care Provider. It is the responsibility of the specialist’s office to ensure that the member has a valid referral before rendering services. PCHP specialists must: • Be licensed to practice medicine or osteopathy in the state of Texas; • Have admitting privileges at a PCHP participating hospital; • Obtain referral form from the member’s Primary Care Provider, and approved by PCHP, before rendering services; • Assure that the consultation report and recommendations are sent to the Primary Care Provider and communicate with the Primary Care Provider regarding the member’s status and course of treatment; • Tell the member and/or family of the diagnostic, treatment, and follow-up recommendations in consultation with the Primary Care Provider (if appropriate); and, • Provide members/families with appropriate health education in the management of the member’s special needs. Acceptable: 1. Office phone is answered after hours by an answering service. All calls answered by an answering service must be returned by a provider within 30 minutes.
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 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 and 76: Member’s Right to Designate an OB
Page 77: 70 To report providers use this add
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.

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?