PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Disenrollment For those members who are disenrolled because they are no longer eligible for CHIP, the HMO will receive from the Administrative Services Contractor notice informing the HMO that the members’ coverage will end on a particular date. Disenrollment due to loss of eligibility includes, but is not limited to; “aging-out” when a child turns 19, failure to re-enroll at the conclusion of the 12-month eligibility period, change in health insurance status, failure to meet monthly cost–sharing obligation, death of the child, child permanently moves out of the state, and data match with the Medicaid system indicates dual enrollment in Medicaid and CHIP. Parkland KIDSfirst has a limited right to ask for a member be disenrolled from the Plan without the member’s consent. KIDSfirst’s request to disenroll a member from the Plan will require medical documentation from the member’s Primary Care Provider or documentation that indicates sufficiently compelling circumstances that merits disenrollment. HHSC must approve and will make the final decision on any request by KIDSfirst for disenrollment of a member for cause. • We will take reasonable measures to correct a member’s behavior before asking for disenrollment. Reasonable measures can include providing education and counseling regarding the offensive acts or behaviors. • If all reasonable measures fail to remedy the problem, Parkland KIDSfirst will inform the member of the decision to recommend disenrollment to HHSC. • We cannot ask for a disenrollment based on adverse change in the member’s health status or utilization of services that are medically necessary for treatment of a member’s condition. • Additionally, a provider cannot take retaliatory action against a member who is disenrolled from Parkland KIDSfirst. Plan Changes Members are only allowed to make plan changes once a year. Members can ask to change health plans for exceptional reasons or good cause. HHSC must approve and will make the final decision on any request by members to change health plans. CHIP Perinatal Member Enrollment and Disenrollment Enrollment The mother of the CHIP Perinate has 15 calendar days from the time the enrollment packet is sent by the vendor to enroll in an MCO (where choice is available). Newborn Process • All CHIP and CHIP Perinatal members in a household must be enrolled in the same MCO. Upon certification of CHIP Perinatal eligibility, children in the same household enrolled in CHIP must be prospectively enrolled in the MCO providing the CHIP Perinatal coverage and disenrolled from their current MCO the first possible month. Co-payments, cost-sharing and enrollment fees still apply to children enrolled in CHIP. 91
• In order to synchronize all CHIP and CHIP Perinatal members in a household, all members will remain in the MCO providing CHIP Perinatal coverage until the CHIP Perinate Newborn completes its 12- month eligibility. After the CHIP Perinate Newborn’s coverage period is completed, the child will be added to the existing CHIP case. The coverage period for the newly enrolled child will be the remaining period of coverage of the siblings already enrolled in CHIP. Disenrollment HHSC must approve and will make the final decision on any request for disenrollment of a member for cause. A provider cannot take retaliatory action against a member who is disenrolled from Parkland CHIP Perinate or Parkland CHIP Perinate Newborn. Plan Changes 92 • Once the mother of the CHIP Perinate picks an MCO, the CHIP Perinate must remain in this MCO until the end of the CHIP Perinatal continuous eligibility period. • If the mother of the CHIP Perinate does not pick an MCO within 15 calendar days of receiving the enrollment packet, the CHIP Perinate is defaulted into an MCO and the mother is notified of the plan choice. When this happens, the mother has 30 days to pick another MCO. • All CHIP and CHIP Perinatal members must remain in the same MCO until the end of the CHIP Perinatal continuous eligibility period. After the CHIP Perinate Newborn’s coverage period is completed, the child will be added to the existing CHIP case. The coverage period for the newly enrolled child will be the remaining period of coverage of the siblings already enrolled in CHIP. At the first CHIP renewal after the CHIP Perinatal eligibility ends, the family can pick a new MCO. Note: The switch of the CHIP members from their MCO to the MCO providing the CHIP Perinatal coverage does not count as their one MCO change per year. • Members can ask to change MCOs for exceptional reasons or good cause. Provider Marketing Guidelines The following CHIP provider marketing policy is consistent with HHSC Marketing Policies and Texas Department of Insurance standards. CHIP Provider Marketing Policy • Health care providers can undertake a variety of activities designed to urge families to apply for CHIP. Examples include, but are not limited to: • Displaying posters, brochures, or other written material • Distributing application booklets to families with uninsured children • Playing a video that promotes CHIP • Informing their patients of the toll-free CHIP Help Line • Providers can educate their patients about CHIP specifically. • Providers can not promote the selection of specific health plans within the context of the CHIP enrollment process. • Providers can not help families in filling out the health plan selection form. • Providers can not distribute health plan marketing materials in their offices.
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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
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As the Primary Care Provider you mu
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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 and 94: (PP) Attending physician ID (UB-04,
Page 95 and 96: (2) post-partum visits within 60 da
Page 97: CHIP Member Enrollment and Disenrol
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
Page 145 and 146: Follow-up • Follow-up urine cultu
Page 147 and 148: 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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