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2022 Provider ManualCHIP PlanCHIP Provider ServicesPROVIDER SERVICES (210) 358-6300Toll Free 1-800-434-2347CommunityFirstMedicaid.comAtascosa Bandera Bexar Comal Guadalupe Kendall Medina WilsonCFHP 1499GOV 1021
EXHIBITSExhibits referred to throughout this Provider Manual can be accessed by clicking the respective linksbelow or by visiting ources/providers/.EXHIBITTITLEExhibit 1Request for Continuity/Transition of CareExhibit 2Your Texas Benefits Medicaid CardExhibit 3aCommunity First CHIP Member ID CardExhibit 3bCommunity First CHIP Perinate Member ID CardExhibit 3cCommunity First CHIP Neonate Member ID CardExhibit 4Provider Request for Member TransferExhibit 5Request for Increase in 1,500 CapacityExhibit 6Texas Standard Prior Authorization Request Form for Health Care ServicesExhibit 7Tuberculosis Report of Case and Patient ServicesExhibit 8American Academy of Pediatrics Recommendations for Preventive Pediatric Health CareExhibit 9Sterilization ConsentExhibit 10Psychological Testing Request FormExhibit 11Member Education Request FormExhibit 12Medical Record Review ToolExhibit 13Member/Client Acknowledgement StatementExhibit 14CDC Vaccine Information for AdultsExhibit 15Consent to Use a Physician Assistant/Nurse PractitionerExhibit 16CMS 1500 Claim Form and Instruction TableExhibit 17UB 04 Claim Form and Instruction TableExhibit 18Private Pay AgreementExhibit 19Explanation of Payment (EOP) - SampleCHIP Provider Manual Community First Health Plans1
EXHIBITTITLEExhibit 20Provider Complaint FormExhibit 21Claim Appeal Submission FormExhibit 22Medicaid Eligibility Verification Form (H 1027-A)Exhibit 23Current Immunization Schedule for PediatricsExhibit 24Blood Lead Screening and Testing GuidelinesExhibit 25Home Health Services (Title XIX) DME/Medical Supplies Physician Order FormExhibit 26Provider Billing GuidelinesExhibit 27Form H3038, Emergency Medical Services CertificationCHIP Provider Manual Community First Health Plans2
QUICK REFERENCE PHONE LISTCONTACTPHONE NUMBERMember Services Department1-800-434-2347 (toll-free)(210) 358-6300Member Services Fax(210) 358-6099Eligibility/Benefits Verification(210) 358-6300Interpreter Services/Sign Language(210) 358-6300Population Health Management(210) 358-6050Preauthorization Fax(210) 358-6040Urgent Care(210) 227-2347Behavioral Health Authorization/Care Management(210) 358-6100 (Option 3)1-800-434-2347 (Option 3)Behavioral Health Fax(210) 358-6387NICU Fax(210) 358-6388TTY (For the Deaf and Hard of Hearing)1-800-390-1175Provider Relations (General Inquiries)Provider Relations (Claims Assistance)(210) 358-6294(210) 358-6030Claims Information(210) 358-6200Claims Fax(210) 358-6199Electronic ClaimsAvaility Payor ID: COMMFNurse Advice Line(After hour calls are forwarded to Nurse Advice Line)(210) 358-6300Preventive Health and Disease Management1-800-434-2347Community Outreach Agencies(210) 358-6159Pharmacy-Navitus Health Solutions1-866-333-2757Vision InquiriesEnvolve Benefit Options1-800-334-3937Dental InquiriesDentaQuestMCNA DentalUnited Healthcare IP Provider Manual Community First Health Plans3
CHIP Provider Manual Community First Health Plans4
TABLE OF CONTENTSEXHIBITS. 1QUICK REFERENCE PHONE LIST . 3A.Introduction . 131.Background and Objectives of Program . 132.Role of the CHIP Member Primary Care Provider (PCP) . 143.Role of the CHIP Member Specialty Care Provider . 174.Role of the CHIP Perinate Newborn Primary Care Provider . 175.Role of the CHIP Perinate Newborn Specialty Care Provider . 176.Network Limitations . 187.Providers for Members with Disabilities, Children with Special Health Care Needs(CSHCN), and/or Chronic/Complex Conditions . 188.Role of Pharmacy and Pharmacy Provider. 199.Role of Main Dental Home . 1910.How to Help a Member Find Dental Care . 19B.CHIP and CHIP Perinate Newborn Covered Services . 201.CHIP Schedule of Benefits. 202.CHIP Perinate Newborn Schedule of Benefits. 373.CHIP and CHIP Perinate Exclusions from Covered Services . 514.Durable Medical Equipment (DME) and Other Products Normally Found in a Pharmacy535.CHIP Pharmacy Program . 616.CHIP and CHIP Perinate Newborn Extra Benefits (Value-Added. 65Services) . 65C. Coordination with Non-CHIP/CHIP Perinate Newborn Covered Services (Non-CapitatedServices). 691.Texas Agency Administered Programs and Case Management Services . 69CHIP Provider Manual Community First Health Plans5
2.Essential Public Health Services. 693. Family Planning Services . 804. Access to Telemedicine, Telemonitoring, and Telehealth. 89D. Behavioral Health . 891.Behavioral Health Definitions. 892.Behavioral Health Covered Services. 913.PCP Requirements for Behavioral Health . 914.Behavioral Health Services . 925.Emergency Behavioral Health Services . 966.Behavioral Health Value-Added Services . 97E. Emergency, Urgent, and Routine Care Services . 971. Definitions of Emergency, Urgent, and Routine Care. 972. Emergency Transportation . 1003.Member/Client Acknowledgment Statement . 1004.Private Pay Form Agreement . 1015.Emergency Prescription Supply . 1026.Emergency and Non-Emergency Dental Services . 103F.Provider Responsibilities . 1031.Primary Care Provider (Medical Home) Responsibilities . 1032.Availability and Accessibility . 1053.Plan Termination Process. 1094.Member’s Right to Designate an OB/GYN . 1105.Optometry and Ophthalmology Services . 1116.Access to Medication. 1117.How to Help a Member Find Dental Care . 1118.Advance Directives . 1119.Referral to Specialists and Health-Related Services. 112CHIP Provider Manual Community First Health Plans6
10.PCP and Behavioral Health Related Services . 11211.Referral to Network Facilities and Contractors . 11212.Access to a Second Opinion . 11313.Specialty Care Provider Responsibilities . 11314.Verifying Member Eligibility and/or Authorization for Services . 11615.Continuity of Care . 11916.Transition and Continuity of Care . 12017.Justification for Out-of-Network Authorizations . 12018.Coordination with Texas Department of Family and Protective Services (DFPS) . 122G.Member Eligibility and Enrollment . 1221.Member Eligibility . 1222.Member Enrollment, Re-enrollment, and Disenrollment. 124H.Special Access Requirements . 1271.Interpreter/Translation Services . 1272.Community First and Provider Coordination . 1273.Reading/Grade Level Consideration . 1284.Cultural Sensitivity . 1283. Children with Complex and Special Health Care Needs. 128I.CHIP Member Rights and Responsibilities . 1291.CHIP Member Rights. 1292.CHIP Member Responsibilities . 131J.Preventive Health and Disease Management . 1321.Diabetes in Control: Diabetes Management Program . 1332.Asthma Matters: Asthma Management Program . 1343.Healthy Expectations Maternity Program . 1364.Healthy Mind: Behavioral Health Program . 1375.Healthy Living: Healthy Lifestyle Management Program . 138CHIP Provider Manual Community First Health Plans7
4. Healthy Heart: Blood Pressure Management Program . 139II.CHIP PERINATE PROGRAM FOR PREGNANT WOMEN . 142A.Introduction . 1421.Background and Objectives of Program . 1422.Important Changes in Application Process for Emergency Medicaid . 1423.Role of CHIP Perinatal Provider . 1434.Role of Pharmacy and Pharmacy Provider. 144B.CHIP Perinate Covered Services . 1441.CHIP Perinate Schedule of Benefits . 1442.Exclusions from Covered Services for CHIP Perinates (Unborn) . 1553.CHIP Perinate Extra Benefits (Value-Added Services) . 158C. Coordination with Non-CHIP Perinate Covered Services (Non-Capitated Services). 1601.D.Case Management for Children and Pregnant Women . 161OB/GYN Responsibilities . 1631.Access to OB/GYNs. 1632.Availability Standards for OB/GYNs . 1643.Member’s Right to Designate an OB/GYN . 165E.Pregnancy Verification Requirements for CHIP Perinate . 165F.Member Eligibility. 166G.1.Member Eligibility . 1662.Pregnancy and CHIP Perinate Eligibility . 1663.Span of Eligibility . 1674.CHIP Perinate Member Plan Changes . 1675.Involuntary Disenrollment . 168CHIP Perinate Member Rights and Responsibilities . 169H. Healthy Expectations Maternity Program. 171III.REQUIREMENTS & INFORMATION COMMON TO ALL CHIP PROGRAMS . 174CHIP Provider Manual Community First Health Plans8
A.Legal and Regulatory. 1741.Law, Rules, and Regulations . 1742.Liability . 1753.Medical Consent Requirements . 1764.Member Communication . 1765.Fraud, Waste, and Abuse . 1766.Reporting Abuse, Neglect, and Exploitation . 1787.Insurance . 1808.Marketing. 1809.Provider Network Requirements . 18110.Non-Discrimination by Participating Provider . 18111.Medical Records Documentation Guidelines . 18212. Credentialing and Recredentialing . 18713. Updates to Contact Information . 19014.Mandatory Challenge Survey . 19015.Confidentiality . 19116.Potentially Preventable Complications (PPC) and ProviderPreventable Readmissions(PPR) . 191B.Quality Improvement Program . 1931.Delegation of QIP Activities . 1942.Practice Guideline Development . 1943.Focus Studies and Utilization Management Reporting Requirements. 1954. Office Site Visit/Potential Quality Issues (PQIs) . 196C.Utilization Management. 197D.Provider Complaint and Appeal Process . 1981.Provider Complaints to Community First . 1982.Provider Appeals to Community First . 199CHIP Provider Manual Community First Health Plans9
3.Provider Complaint and Appeal Process to TDI . 201E. Member Complaint/Appeal Process . 2011.Member Complaints to Community First. 2012.Member Appeals . 2033.Member Expedited Appeal . 2044.Member Independent Review Organization (IRO) . 2055.Appealing an Adverse Determination . 206F. Encounter Data, Billing, and Claims Administration. 2071. Where to Send Claims/Encounter Data . 2072. Claim Form . 2093.Emergency Services Claims . 2094.Pharmacy Claims . 2105.Cost Sharing Schedule . 2106.Member Billing . 2127. Time Limit for Submission of Claims . 2135. Claims Submission . 2139.EOP, Duplicate Checks, and Canceled Check Requests . 21510.Special Billing . 21511.Billing and Claims Administration . 21612. Claims Questions/Appeals . 21913.G.Electronic Funds Transfer and Electronic Remittance Advice . 219Special Access Requirements . 2191.Interpreter/Translation Services . 2192.Community First and Provider Coordination . 2203.Reading/Grade Level Consideration . 2204.Cultural Sensitivity . 220CHIP Provider Manual Community First Health Plans10
CHIP Provider Manual Community First Health Plans11
SECTION ICHIP & CHIP PERINATE NEWBORN PROGRAMS Information found in this section (Section I of this Provider Manual) applies to the CHIP andCHIP Perinate Newborn Programs only. Please refer to Section II for information applicable to the CHIP Perinate Program only. Please refer to Section III for requirements and information applicable to all CHIP programs.CHIP Provider Manual Community First Health Plans12
I.CHIP & CHIP PERINATE NEWBORN PROGRAMSWelcome to the Community First Health Plans Children’s Health Insurance Program(CHIP) network.A. Introduction1.Background and Objectives of ProgramCHIP is a managed care plan for uninsured children in Texas.The Community First CHIP/CHIP Perinate Newborn network comprises physicians,allied and ancillary health care providers, hospitals, and other facilities selected toprovide quality health care to our CHIP Members. The primary care provider (PCP) isresponsible for managing the overall medical care of patients and coordinating referralsto specialists and inpatient/outpatient facilities. The PCP is a Community First networkprovider with one of the following specialties/practice areas: General PracticeFamily PracticeInternal MedicineObstetrics and Gynecology (pregnant women only)PediatricsFederally Qualified Health Centers (FQHCs)Rural Health Clinics (RHCs)In addition, Community First Members can access contracted Advance Practice Nurses(APN), Physician Assistants (PA), and Certified Nurse Midwives (CNM), practicingunder the supervision of a physician for appropriate covered services.This Provider Manual is designed to assist you and your staff in working with us todeliver quality health care to Community First CHIP/CHIP Perinate NewbornMembers. It provides information regarding our utilization and quality managementprograms, preauthorization and referral notification procedures, claims filing processes,and our appeals process. We encourage you and your staff to review this Manualcarefully and contact your Provider Relations Representative if you have any questions,CHIP Provider Manual Community First Health Plans13
comments, or concerns. We welcome suggestions from you and/or your staff forenhancing this Manual.We will mail updates to your office to advise you of any changes/updates to thisManual. In addition, Community First publishes and distributes a quarterly newsletterto all network physicians and providers. The newsletter includes information such asCHIP/CHIP Perinate Newborn services, policies and procedures, statutes, regulations,and claims processing information. Community First also uses fax alerts, bannermessages, special mailings, and our website as additional means to communicatechanges/updates to you and your staff.Following the initial orientation session for Community First CHIP/CHIP PerinateNewborn network physicians and Providers, Community First will have ongoingtraining sessions when requested by the Provider or deemed necessary by CommunityFirst or the Texas Health and Human Services Commission (HHSC). Prior to theeffective date of the renewal of our agreement with HHSC, Community First willschedule provider orientations for existing Providers to review program requirements,including changes to covered services, authorization requirements, and claimssubmission procedures and/or appeal timeframes.2.Role of the CHIP Member Primary Care Provider (PCP)PCPs play an integral role in helping meet the objectives of the CHIP program. Theprogram places its main focus on the total well-being of the Member, while providing a"Medical Home" where the Member can readily access preventive health care servicesand treatment, as opposed to episodic health crisis management. Members areencouraged to become more involved in their own health care and maintain their ownwellness. The PCP is responsible for teaching Members how to use available healthservices appropriately.PCPs will provide preventive health services in accordance with the program, andrelated medical policies. They also will coordinate the provision of all covered servicesto CHIP/CHIP Perinate Newborn Members by: Serving as a Medical Home.Initiating referrals to network specialty care physicians, network facilities, andallied health care providers.Monitoring the Member’s progressFacilitating the Member’s return to the PCP when medically appropriate.CHIP Provider Manual Community First Health Plans14
Educating Members and their families regarding their medical care needs.Please review the American Academy of Pediatrics Recommendations for PreventivePediatric Health Care (Exhibit 8) and the CDC’s Recommended Child andAdolescent Immunization Schedule (Exhibit 23).In addition, the PCP must have screening and evaluation procedures for detection andtreatment of, or referral for, any known or suspected behavioral health problems anddisorders.The PCP must obtain the Member’s consent when seeking services from a PhysicianAssistant or Nurse Practitioner using the Supervising Physician Approval Form(Exhibit 15).The PCP will provide, or arrange for the provision of, covered services, and/ortelephone consultations during normal office hours, as well as on an emergency basis,24 hours a day, seven days a week. The PCP is responsible for arranging andcoordinating appropriate referrals to other physicians and/or health care providers andspecialists and for managing, monitoring, and documenting the services of otherproviders.Community First has contracted with an interpreter service for any Provider office thatdoes not have bilingual employees or sign language interpreters. Services are availablefor sign language, Spanish, English, Vietnamese, and other languages that may bespoken by our CHIP Members. The service is accessible 24 hours a day, seven days aweek. Providers can use the service during normal business hours by calling theMember Services Department at (210) 358-6060 or 1-800-434-2347. After hours andon weekends, requests for interpreter services are answered
2022 Provider Manual CHIP Plan CFHP_1499GOV_1021 CHIP ProvIder ServICeS ProvIder ServICeS (210) . CONTACT PHONE NUMBER Member Services Department 1-800-434-2347 (toll-free) (210) 358-6300 . DentaQuest . MCNA Dental . United Healthcare Dental 1-800-516-0165 : 1-800-494-6262 .
