PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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