PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

(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.
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