PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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RHCs 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 CHIP Type of Service Codes to Bill Reimbursement General Services T1015 (CMS 1450) Encounter rate Well child check ups CPT (CMS 1500) Encounter rate Additional Items: • Co-pay as appropriate to CHIP plans will apply to T1015 codes • Follow-up visits after well child exam billed with 99211 and a well diagnosis code of V20.2, V20.31, or V20.32 will be denied. • FQHCs and RHCs will be instructed to bill their NPI in both billing and rendering fields on the claim for STAR and CHIP. Clients with income above 185-200% of Federal Poverty Level: Hospital facility charges related to labor with delivery for a Parkland CHIP Perinate and the initial hospital admission of a Parkland CHIP Perinate Newborn should be mailed to: 87 Parkland Community Health Plan Attn: Claims Department PO Box 61088 Phoenix, AZ 85026 Electronic submission can be performed by submitting EDI claims to Payor ID 66917 to Emdeon. Providers can contact Emdeon at 1-800-735-8254 for assistance. Required formats are CMS 1500 –NSF (National Standard Format 2.0) and UB-04 (previously known as UB-92) –ANSI. Providers have 95 days from date of service to submit claims for services. Authorization numbers must be included on CMS 1500 field # 23 and UB-04 field # 63. Parkland CHIP Perinate and Parkland CHIP Perinate Newborn are obligated to pay all clean claims within 30 days of receipt. Special Billing Newborns It can take many weeks to process the newborn’s member ID card once the newborn is enrolled. In the interim, use the mother’s ID card when administering care to the newborn. If after 31 days the newborn still has not received an ID card, please contact PCHP Member Services at the number listed on page 1 of this manual. For Primary Care Providers If your office provided routine newborn hospital care for Parkland KIDSfirst or Parkland CHIP Perinate Newborn members, submit your bill electronically or on a CMS-1500 form to PCHP. If a referral is necessary or a newborn not yet appearing on the primary office list, use the mother’s member ID number. CHIP Perinate Antepartum and Post-Partum Care CHIP Perinatal contracted providers are required to provide both antepartum and post-partum services to Parkland CHIP Perinate members within their care. Parkland CHIP Perinate members are eligible for two
(2) post-partum visits within 60 days of delivery. Members who miscarry are also eligible for two (2) visits within 60 days of the miscarriage. CHIP Perinatal providers should submit bills electronically or on a CMS-1500. Initial prenatal care visits are payable using the appropriate ICD-9 code related to pregnancy as the primary diagnosis and one of the following procedure codes 99201, 99202, 99203, 99204 or 99205 for the level of service rendered. The procedure codes for the first prenatal visits are limited to one per pregnancy, same provider. High risk pregnancy visits should be billed using the appropriate procedure codes based on level of care and complexity of the visit. Antepartum care visits should be billed using the appropriate ICD-9 code related to pregnancy as the primary diagnosis and one of the following procedure codes 99211, 99212, 99213, 99214 or 99215 for the level of service rendered. Post-partum care visits should be billed using the appropriate ICD-9 code related to post-partum services and CPT code 59430. Both antepatum and post-partum services should be billed using the TH modifier. Providers should refer to the Covered Services grid starting on page 22 of this manual for more detail on covered services. Inpatient Services Before Enrollment If a PCHP member’s Start Date of Coverage occurs while the member is confined in a hospital, PCHP is responsible for the costs of covered services beginning on the Start Date of Coverage. Discharge after Disenrollment If a PCHP member is disenrolled while the member is confined in a hospital, PCHP’s responsibility for the cost of covered services ends on the date of disenrollment. Claims Appeals An appeal is a request for reconsideration of a previously dispositioned claim. PCHP must receive all appeals of denied claims and requests for adjustments on paid claims within 120 days from the date of disposition of the Explanation of Benefits (EOB) on which that claim appears. If the 120-day appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day. Appeal the claim by completing the following steps: 1) Make a copy of the EOB page where the claim is reported or other official notice from TMHP. 2) Circle one claim per EOB page. 3) Identify the incorrect information and the corrected information that should be used to appeal the claim. 4) Specify the reason for appealing the claim. 5) Attach a copy of supporting medical documentation that is necessary or requested by PCHP. 6) Attach a copy of the original claim if available. Claim copies are helpful when the appeal involves medical policy or procedure coding issues. Reminder: Do not copy supporting documentation on the opposite side of the EOB. 88
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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 •
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SUPPLIES COVERED EXCLUDED COMMENTS/
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SUPPLIES COVERED EXCLUDED COMMENTS/
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Coordination between Physical and B
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in the provision of care and servic
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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 and 92: (DD) Diagnosis code by specific ser
Page 93: (PP) Attending physician ID (UB-04,
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
Page 143 and 144: 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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