PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

• Any service that is not a benefit of the Texas Children’s Health Insurance Program. (for example, personal
care items).
• All services are incurred on non-covered days due to eligibility or spell of illness limitation. Total member
liability should be decided by reviewing the itemized statement and identifying specific charges incurred on
the non-covered days. Spell of illness limitations do not apply to medically necessary stays.
• The reduction in payment is due to the medically needy spend-down. The member’s potential liability
would be equal to the amount of total changes applied to the spend down. Charges to members for services
provided on ineligible days must not exceed the charges applied to spend-down.
Filing Limits
All claims must be submitted within ninety-five (95) days from the date the covered service was rendered.
If the claim is not filed with PCHP within ninety-five (95) days from the date the covered service was rendered,
the right to payment will be waived by the participating provider. Payment will not be waived if the
participating provider establishes to the reasonable satisfaction with PCHP that there was reasonable
justification for a delay in billing or that delay was caused by circumstances beyond the participating provider’s
control.
Participating providers shall be paid by PCHP, no later than thirty (30) days after receipt by PCHP of a completed
“clean” claim for covered services. A clean claim is one that is accurate, complete (i.e., includes all information
necessary to determine PCHP liability), not a claim on appeal, and not contested (i.e., not reasonably believed to be
fraudulent and not subject to a necessary release, consent or assignment). PCHP will explain to participating providers
within thirty (30) days of PCHP receipt of claims if claims received are not clean claims.
PCHP must pay providers interest on a clean claim, which is not adjudicated within thirty (30) days from the date the
claim is received by PCHP at a rate of 1.5% per month (18% annual) for each month the clean claim remains unadjudicated..
Should you have a question about claim issues, please feel free to call us at 1-888-814-2352.
All out-of-network claims must be submitted within 95 days of the date of service.
Clean Claim Requirements
The following are clean claim submission requirements as specified by the Texas Department of Insurance
(TDI):
Clean Claim Elements: Parkland Community Health Plan will adhere to the elements of a clean claim as
described in Texas Administrative Code Title 28, Part 1, Chapter 21, Subchapter T, Rule § 21.2803.
Required data elements. CMS has developed claim forms which provide much of the information needed to
process claims. Two of these forms, CMS 1500 and UB-82/CMS, and their successor forms, have been
identified by Insurance Code Article 21.52C as required for the submission of certain claims. The terms in
paragraphs (1) and (3) of this subsection are based upon the terms used by CMS on successor forms CMS- 1500
and UB-92 (UB-04) CMS-1450 claim forms. The parenthetical information following each term refers to the
applicable CMS claim form, and the field number to which that term corresponds on the CMS claim form.
(1) Required form and data elements for physicians or noninstitutional providers for claims filed or refiled
on or after the later of July 18, 2007, or the earliest compliance date required by CMS for mandatory use
of the CMS-1500 (08/05) for Medicare claims. The CMS-1500 (08/05) and the data elements described in this
paragraph are required for claims filed or re-filed by physicians or noninstitutional providers on or after the later
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