PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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2. Office phone is answered after normal business hours by a recording in the language of each of the major population groups served directing the patient to call another number to reach you or another provider designated by you. Someone must be available to answer the designated provider’s phone. Another recording is not acceptable. 3. Office phone is transferred after office hours to another location where someone will answer the phone and be able to contact you or another designated medical practitioner. Unacceptable: 1. Office phone is only answered during office hours 2. Office phone is answered after hours by a recording, which informs the patient to leave a message. 3. Office phone is answered after hours by a recording which directs patients to go to an emergency room for any services needed. 4. Returning after-hours call outside of 30 minutes. Appointment Availability The following are the PCHP appointment availability standards for specialty providers: Appointment Type Standard Routine Medical Care Within 14 calendar days of request Urgent Medical Care Within 24 hours of request Emergency Care Upon presentation Prenatal Care Within 14 days of request, except for high risk pregnancies or New members in the third trimester for whom an appointment must be offered within 5 days, or immediately, if an emergency exists Initial Behavioral <strong>Health</strong> Care Within 14 calendar days of request Routine Behavioral <strong>Health</strong> Care Within 14 calendar days of request 73 Other Access Standards Service Standard After hours Coverage must be available after normal posted business hours 7 days a week, 365 days a year After hours calls returned < 30 minutes In-office wait time < 30 minutes Responsibility to Verify Member Eligibility and/or Authorization for Services All members are issued a PCHP ID card at the time of enrollment with us. Eligibility should be verified before rendering services by calling Member Services at 1-888-842-3862 or by visiting the website at www.parklandhmo.org All members must be referred by their Primary Care Provider for specialist services other than for OB/Gyn, well child services and value-added services. Eligibility should be verified before rendering services by calling PCHP’s Member Services 1-888-814-2352. Specialist as Primary Care Provider – Chronic or Complex Conditions Specialty care providers can also act as Primary Care Provider’s under specific circumstances for children with chronic and or complex health conditions. By allowing a specialist to act as a Primary Care Provider, PCHP will allow members to draw upon the most appropriate care to meet their needs and live a more healthy life. A specialist that is serving as a Primary Care Provider must adhere to all of the Primary Care Provider requirements. (See Provider Responsibilities under Primary Care Services.)
To request to be a Specialist serving as a primary care provider, please contact Provider Relations at 888-672- 2277. Determination will be made in a reasonable timeframe. If this request is denied, an enrollee may appeal the decision through the HMO’s established complaint and appeal process. Please refer to the complaint and appeal section for more information. If the request for special consideration of a non-primary care physician specialist to act as a primary care physician is approved, the HMO may not reduce the amount of compensation owed to the original primary care physician for services provider before the date of new designation. If medically necessary covered services are not available through network physicians or providers, the HMO on request of a network physician or provider and within a reasonable time shall allow referral to a non-network physician or provider and fully reimburse the non-network physician or provider at the usual and customary rate or at an agreed rate. "Within a reasonable time" means with the time appropriate to the circumstances relating to the delivery of the services and the condition of the patient, but in no even to exceed five business days after receipt of reasonably requested documentation. An HMO must provide for a review by a specialist for the same or similar specialty as the type of physician or provider to whom a referral is requested before the HMO may deny a referral. When a Member Accesses Care What to do when a PCHP member presents for services: • The member guardian will call to make an appointment with their Primary Care Provider. • Confirm if the patient is a CHIP member. • Upon arrival for their appointment, ask the member to show their PCHP Identification Card. • If the member cannot produce their ID card, call our Member Services Department at 1-888-814-2352, check the monthly enrollment panel provided by PCHP, or verify enrollment via our website www.parklandhmo.org. • Referrals to doctors, other than the member’s Primary Care Provider, require approval and completion of a referral form by the Primary Care Provider or preauthorization from PCHP. Should you have any questions regarding referrals, please review the “Referral” section of this manual. • The provider might need to obtain prior-authorization from PCHP before initiating certain procedures, admissions or specialty services. Please review the list of services and procedures requiring priorauthorization as documented in the “Prior Authorization” section of this manual. Emergency Services and Care If member needs immediate treatment, proceed and treat. Within 24 hours of an emergency admission or an emergency room visit, the provider must notify PCHP and the Primary Care Provider with the following information: • Member’s Full Name • Member identification Number • Diagnosis for emergency admission • Facility where member was admitted • Admitting doctor name Notification of Changes in Medical Office Staffing and Addresses; Providers must provide notice, in writing, to PCHP of any changes in the following information: 74
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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
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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 and 78: 70 To report providers use this add
Page 79: 5. Network providers must report an
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
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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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