PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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The fields indicated below are specific to the NPI implementation. Field Definition Description Requirement 11 c 17 17a 17b Insurance <strong>Plan</strong> or Program Name Referring Provider or Other Source Other ID# NPI Enter the benefit code, if applicable, for the billing or performing provider. Name of the professional who referred or ordered the service(s) or supply(s) on the claim. The Other ID number of the referring provider, ordering provider, or other source should be reported in 17a. Enter the NPI of the referring provider, ordering provider, or other source. Benefit code, if applicable NPI NPI or Atypical NPI 24j Rendering Provider ID# (Performing) The individual rendering the service should be reported in 24j. Enter the TPI in the shaded area of the field. Enter the NPI in the unshaded area of the field. TPI in shaded field and NPI in un - shaded area 32 Service Facility Location Information Enter the name, address, city, state, and ZIP code of the location where the services were rendered. Enter facility information when applicable 32a NPI Enter the NPI of the service facility location. NPI 32b Other ID# Enter the non-NPI ID number of the service facility. This refers to the payer-assigned unique identifier of the facility. TPI 33 Billing Provider Info and Ph. No. Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. The billing provider’s information 33a NPI Enter the NPI of the billing provider. NPI 33b Other ID# Enter the non-NPI ID number of the service facility. This refers to the payer-assigned unique identifier of the facility. TPI required UB-04 Institutional Claim Form The NUCC approved the UB-04 CMS-1450 claim form as the replacement for the UB-92 HCFA-1450 claim form. Beginning May 21, 2007, providers must use the revised UB-04 CMS-1450 claim form to submit or resubmit claims, including appeals, regardless of the version used for prior submissions. 77
The table below provides HHSC Managed Care Organizations paper claim filing requirements. The fields indicated below are specific to the NPI Implementation. Field Definition Description Requirement 56 NPI Enter the NPI of the billing provider. NPI 57a Other ID# Enter the non-NPI ID number of the billing provider. TPI (optional) 73 Benefit Code Enter the benefit code, if applicable, for the billing provider. Benefit code, if applicable (optional) 76 Attending Provider 77 Operating Provider 78-79 Other (a or b) Provider Attending provider name and identifiers (including NPI): Required when claim/encounter contains any services other than nonscheduled transportation services. The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim/encounter. Operating provider name and identifiers (including NPI): Required when a surgical procedure code is listed on the claim. The name and ID number of the individual with the primary responsibility for performing the surgical procedure(s). Other provider name and identifiers (including NPI): The name and ID number of the individual corresponding to the action of the claim: Referring Provider – The provider who sends the patient to another provider for services. Required on an outpatient claim when the referring provider is different than the attending physician. Other Operating Physician – An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. Rendering Provider – The health care professional who performs, delivers, or completes a particular medical service or non-surgical procedure. NPI required TPI in field to the right of Qualifier box, if applicable NPI required TPI in field to the right of Qualifier box, if applicable NPI required TPI in field to the right of Qualifier box, if applicable Provider shall submit itemized statements on current CMS 1500 or UB-04 claim forms with current HCPC, ICD-9, or CPT-4 coding. Hospitals should submit all claims on a UB-04 claim form for eligible services provided to PCHP members. 78
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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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• Personal comfort items includin
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• 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 and 82: To request to be a Specialist servi
Page 83: • OB/Gyn • Periodic Health Chec
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
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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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