PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Quick Reference Checklist This manual has been designed as a reference source for your use in working with Parkland Community Health Plan (PCHP) members. Important procedures are outlined in the manual and we trust you will find it useful in your day-to-day service to our PCHP members. Should you have additional questions, please call or write: Call us: Parkland Community Health Plan, Inc., Member and Provider Services 1-888-814-2352 (toll-free) 8 a.m. through 5 p.m., Monday through Friday. English/Spanish interpreter services available. After hours phones are answered by Parkland Nurse Line. Write us: Parkland Community Health Plan, Inc. Attn: Parkland KIDSfirst or Parkland CHIP Perinate or Parkland CHIP Perinate Newborn PO Box 569005 Dallas, TX 75356-9005 Visit our Website: www.ParklandHMO.org Providers can access current Provider Directories and Specialist Listings, Provider Manuals, quarterly Provider Newsletters, information about changes and links to other useful websites. Additionally, providers can log-in to a link and get information on claim status and member eligibility. TTY: For persons who are deaf or hard of hearing: please call through the Relay Texas TTY line at 1-800-735- 2989 and ask them to call the Parkland KIDSfirst Member Services Line at 1-888-814-2352. Parkland 24-hour Nurse Line: 1-800-357-3162 or 214-266-8766 (bilingual services available) CHIP Help Line: 1-800-647-6558 Behavioral Health CHIP Members call CompCare at 1-800-945-4644 CHIP Perinate Newborn Members call 1-888-814-2352 Vision Services CHIP Members call Block Vision Services at 1-800-879-6901 CHIP Perinate Newborn Members call 1-888-814-2352 Dental Questions or Dental Information Delta Dental Insurance Company 972-410-3700 DentaQuest 1-800-516-0165 MCNA Dental 1-800-494-6262 1
Welcome to Parkland KidsFirst, Parkland CHIP Perinate and Parkland CHIP Perinate Newborn Introduction The Children’s Health Insurance Program (CHIP) contracts with Managed Care Organizations (MCO) to provide discount health coverage for Texas children under CHIP. Parkland Community Health Plan (PCHP) has expanded upon an existing network of providers and services in answering the request from CHIP to provide managed care services to CHIP eligibles in the Dallas Service Area. PCHP represents three of PCHP’s managed care products sponsored by Parkland Health & Hospital System (PHHS). CHIP’s goal is to achieve five main objectives: • Improved access to care • Improved quality of care • Improved client and provider satisfaction • Improved cost effectiveness • Improved health status We are pleased you have decided to participate with Parkland KIDSfirst, Parkland CHIP Perinate and/or Parkland CHIP Perinate Newborn. Participating in the CHIP program requires a separate contract/or contract amendment for the CHIP Program and its services. If you have questions regarding which program and services you are contracted to participate in, please contact your PCHP Provider Representative. Ranked one of the best hospitals in the United States, PHHS in conjunction with UT Southwestern and Children’s Hospital and our other community providers has maintained a vested interest in the health and well being of Dallas children. The introduction of CHIP to the Dallas Service Area has provided PCHP with the chance to collaborate with other institutions and local providers to enhance the availability of health care to the pediatric population. PCHP is dedicated to being the provider friendly MCO. Our organizational goal is to help our providers care for patients. PCHP staff appreciates your responsiveness to the needs of our membership throughout Dallas, Collin, Ellis, Hunt, Kaufman, Navarro and Rockwall Counties. If you are a participating primary care provider with Parkland KidsFirst and/or Parkland CHIP Perinate Newborn, you will act as the member’s primary care or “medical home” contact that they can go to with medical questions. The Primary Care Provider is responsible for managing all medical care of Parkland KidsFirst and/or Parkland CHIP Perinate Newborn assigned members and taking care of routine medical problems. The Primary Care Provider is also responsible for referrals to a specialist as well as making arrangements for hospital admissions. If you are a participating CHIP Perinatal provider with Parkland CHIP Perinate, you will act as the member’s primary health care provider and contact for medical questions related to care during pregnancy. As a CHIP Perinatal provider you must provide care related to prenatal services, and labor and delivery that is needed by the Parkland CHIP Perinate member. If you are a specialty care provider with Parkland KidsFirst or Parkland CHIP Perinate Newborn, you can provide services 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. Members do not need Primary Care Provider referrals for Behavioral Health, Obstetrical/Gynecological care, or some other 2
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 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
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Presentation at Emergency Room afte
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If the complaint is received verbal
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Expedited Appeal can be made verbal
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CHIP Eligibility CHIP KidsFirst Mem
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• Information concerning the grie
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Parkland Community Health Plan Memb
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Pregnant Teens Please call Parkland
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your income. Co-payments do not app
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Member’s Right to Designate an OB
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70 To report providers use this add
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5. Network providers must report an
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To request to be a Specialist servi
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• OB/Gyn • Periodic Health Chec
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The table below provides HHSC Manag
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CHIP Cost Sharing Caps Members rece
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of these two dates: July 18, 2007,
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(DD) Diagnosis code by specific ser
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(PP) Attending physician ID (UB-04,
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(2) post-partum visits within 60 da
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CHIP Member Enrollment and Disenrol
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• In order to synchronize all CHI
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Provider Participation Requirements
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• Evidence of state licensure, an
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U1 U2 U3 Medically necessary delive
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PROCEDURE DESCRIPTION PROCEDURE COD
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provider actually treating the memb
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themselves appropriately and follow
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Medical Record Standards The medica
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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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