PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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1. Tax identification number 2. Office address 3. Billing address 4. Phone number 5. Billing County 6. Specialty 7. New provider additions/deletions to practice 8. Current license (Drug Enforcement Agency, Department of Public Safety, state license, and malpractice insurance) and its expiration date 9. Status of Board Certification 10. Status of Hospital Privileges (if applicable) If you plan to move your office, open a new location, or you leave your current practice, you should provide written notice at least ninety (90) days before any planned change. By providing this information, you will ensure the following: 75 • Your practice is properly listed in the PCHP Provider Directory; • Payments made to you or your group are properly reported to the Internal Revenue Service; and, • PCHP members are notified in time to change their provider if they so desire as a result of the change. Forward correspondence to: Parkland Community Health Plan Inc. Provider Relations Department 2777 Stemmons Freeway, Suite 1750 Dallas, Texas 75207 Laboratory Tests PCHP providers must refer laboratory tests to in-network facilities and contractors. Exceptions must be approved by PCHP Patient Management. Please refer to the PCHP provider directory or contact Provider Relations at 1-888-814-2352 for information or assistance. Referrals Referrals to providers, other than the member’s Primary Care Provider, require approval or completion of a referral form by Primary Care Provider. Providers should refer members to network facilities and contractors. Please review the “Referral” sub-section of the Medical Management Section of this Manual. Prior Authorization 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 prior authorization as documented in the “Pre-authorization” section of this manual. Specialty Services Available without Referral PCHP members can use the services of the following specialties without a referral from the Primary Care Provider to any in network provider:
• OB/Gyn • Periodic Health Checkups • Value Added Services Access to a Second Opinion PCHP allow members access to a second opinion at no additional cost to the member. Claims Submis s ion PCHP claims can be submitted in an electronic or paper format. Claims Submission Providers can file claims electronically through the PCHP clearinghouses, Emdeon or THIN. The claims must be submitted using the payer ID #66917. PCHP CMS 1500s can be submitted in the standard NSF 2.0 format and the UB-04 (previously known as UB- 92) can be submitted in the standard ANSI format. Emdeon can also accept electronic claims in the MCDS and HCDS formats. Please contact Emdeon customer service for more information at 1-800-735-8254. Paper Claims Providers can also mail paper claims to the following address: Parkland Community Health Plan Attn: Claims Department PO Box 61088 Phoenix, AZ 85026 A provider will bill or require payment, such as a co-pay, from Parkland KIDSfirst members for CHIP covered services. Providers can not bill, or take recourse against PCHP members for denied or reduced claims for services that are within the amount, duration, and scope of benefits of Texas CHIP. Any changes to the location of where to send PCHP claims will be provided within 30 days of the start date of the change. If it is not possible to give thirty (30) days notice before a change in claims processing entities, the filing deadline will be extended by thirty (30) days. Claims Forms The claim forms providers use to submit claims to PCHP are changing to accommodate the National Provider Identifier (NPI). These changes are detailed below. CMS-1500 Professional Claim Forms The National Uniform Claim Committee (NUCC) has released the revised version of the CMS-1500 claim form (version 08/05), which includes fields to incorporate NPI. Beginning June 1, 2007, providers must use the revised CMS-1500 (version 08/05) claim form to file or re-file claims, regardless of which version of the CMS-1500 claim form was used for prior submissions. The table below provides HHSC Managed Care Organization paper claim filing requirements. 76
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
Page 8 and 9:
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 28 and 29:
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 and 80: 5. Network providers must report an
Page 81: To request to be a Specialist servi
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
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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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