PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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85 (K) Admission hour (UB-04, field 13) is required for admissions, observation stays, and emergency room care; (L) Type of admission (e.g., emergency, urgent, elective, newborn) (UB-04, field 14) is required for admissions; (M) Source of admission code (UB-04, field 15) is required; (N) Discharge hour (UB-04, field 16) is required for admissions, outpatient surgeries, or observation stays; (O) Patient-status-at-discharge code (UB-04, field 17) is required for admissions, observation stays, and emergency room care; (P) Condition codes (UB-04, fields 18 - 28) are required if the CMS UB-04 manual contains a condition code appropriate to the patient's condition; (Q) Occurrence codes and dates (UB-04, fields 31 - 34) are required if the CMS UB-04 manual contains an occurrence code appropriate to the patient's condition; (R) Occurrence span codes and from and through dates (UB-04, fields 35 and 36) are required if the CMS UB-04 manual contains an occurrence span code appropriate to the patient's condition; (S) Value code and amounts (UB-04, fields 39 - 41) are required for inpatient admissions. If no value codes are applicable to the inpatient admission, the provider can enter value code 01; (T) Revenue code (UB-04, field 42) is required; (U) Revenue description (UB-04, field 43) is required; (V) HCPCS/Rates (UB-04, field 44) are required if Medicare is a primary or secondary payor; (W) Service date (UB-04, field 45) is required if the claim is for outpatient services; (X) Date bill submitted (UB-04, field 45, line 23) is required; (Y) Units of service (UB-04, field 46) are required; (Z) Total charge (UB-04, field 47) is required; (AA) HMO or preferred provider carrier name (UB-04, field 50) is required; (BB) Prior payments-payor (UB-04, field 54) are required if payments have been made to the physician or provider by a primary plan as required by subsection (d) of this section; (CC) For claims filed or re-filed on or after May 23, 2008, the NPI number of the billing provider (UB-04, field 56) is required if the billing provider is eligible for an NPI number; (DD) Other provider number (UB-04, field 57) is required if the HMO or preferred provider carrier, before June 17, 2003, required provider numbers and gave notice of that requirement to physicians and providers; (EE) Subscriber's name (UB-04, field 58) is required if shown on the patient's ID card; (FF) Patient's relationship to subscriber (UB-04, field 59) is required; (GG) Patient's/subscriber's certificate number, health claim number, ID number (UB-04, field 60) is required if shown on the patient's ID card; (HH) Insurance group number (UB-04, field 62) is required if a group number is shown on the patient's ID card; (II) Verification number (UB-04, field 63) is required if services have been verified pursuant to §19.1724 of this title. If no verification has been provided, treatment authorization codes (UB-04, field 63) are required when authorization is required and granted; (JJ) Principal diagnosis code (UB-04, field 67) is required; (KK) Diagnoses codes other than principal diagnosis code (UB-04, fields 67A - 67Q) are required if there are diagnoses other than the principal diagnosis; (LL) Admitting diagnosis code (UB-04, field 69) is required; (MM) Principal procedure code (UB-04, field 74) is required if the patient has undergone an inpatient or outpatient surgical procedure; (NN) Other procedure codes (UB-04, fields 74 - 74e) are required as an extension of subparagraph (MM) Of this paragraph if additional surgical procedures were performed; (OO) Attending physician NPI number (UB-04, field 76) is required on or after May 23, 2008, if attending physician is eligible for an NPI number; and
(PP) Attending physician ID (UB-04, field 76, qualifier portion) is required. Disclosure of Necessary Attachments: Parkland Community Health Plan will not require an attachment as described in Texas Administrative Code Title 28, Part 1, Chapter 21, Subchapter T, Rule § 21.2803 unless it has given the physician or provider at least 60 calendar days notice before requiring the attachment. The notice will be contained in a revision to the Provider Manual. (Texas Administrative Code Title 28, Part 1, Chapter 21, Subchapter T, Rule § 21.2804) Disclosure of Additional Clean Claim Elements: Should Parkland Community Health Plan decide that it needs to require additional elements for clean claims, these additional elements will be communicated to the physician or provider in a revision to the Provider Manual at least 60 calendar days before requiring the additional elements as elements of a clean claim. (Texas Administrative Code Title 28, Part 1, Chapter 21, Subchapter T, Rule § 21.2805.) Disclosure of Revision of Data Elements, Attachments, or Additional Clean Claim Elements: Should Parkland Community Health Plan decide that it needs to revise its requirements for data elements, attachments or additional clean claim elements, it will provide at least 60 calendar days notice to the physician or provider. Hospital Facility Claims for Parkland CHIP Perinate and Parkland CHIP Perinate Newborn Clients at or below 185% of Federal Poverty Level: Hospital facility charges related to a Parkland CHIP Perinate member’s labor with delivery, and the initial hospital admission of a Parkland CHIP Perinate Newborn member is covered by Emergency Medicaid. Hospitals will need to work with these members to apply for Emergency Medicaid upon presentation to the hospital for services. These claims will be billed to Texas Medicaid and Healthcare Partnership (TMHP) through the TMHP normal billing processes. Please contact TMHP at 1-800-925-9126 or visit their website at www.tmhp.com for details their billing process. Any hospital services rendered to Parkland CHIP Perinate Newborn members after the original newborn hospital discharge will not be considered for reimbursement under Emergency Medicaid, but can be covered under CHIP (see the CHIP Perinate Newborn scope of benefits), Hospitals should urge mothers to apply for “regular” Medicaid for the newborn only if the child has a medical condition that is not considered normal for a newborn. FQHC/RHC Reimbursement FQHCs STAR Type of Service Codes to Bill Reimbursement General Services T1015 (CMS 1450) Encounter rate THSteps CPT (CMS 1500) Encounter rate Family Planning CPT (CMS 1500) Encounter rate Vision CPT (CMS 1500) Encounter rate Behavioral Health CPT (CMS 1500) Encounter rate CHIP Type of Service Codes to Bill Reimbursement General Services T1015 (CMS 1450) Encounter rate Well child check ups CPT (CMS 1500) Encounter rate Vision CPT (CMS 1500) Encounter rate Behavioral Health CPT (CMS 1500) Encounter rate 86
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Parkland KIDSfirst, Parkland CHIP P
Page 3 and 4:
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
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• Donor non-medical expenses •
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SUPPLIES COVERED EXCLUDED COMMENTS/
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SUPPLIES COVERED EXCLUDED COMMENTS/
Page 38 and 39:
Coordination between Physical and B
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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 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: (DD) Diagnosis code by specific ser
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
Page 135 and 136: Appendix D Clinical Practice Guidel
Page 137 and 138: Appendix D - Continued Clinical Pra
Page 139 and 140: Appendix D - Continued Clinical Pra
Page 141 and 142: 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
Page 149 and 150:
RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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