2022 Provider Manual

1 2022 Provider ManualCHIP PlanCFHP_1499 GOV_1021 CHIP Provider ServICeS Provider ServICeS (210) 358-6300 Toll Free Bandera Bexar Comal Guadalupe Kendall Medina Wilson CHIP Provider Manual | Community First Health Plans 1 EXHIBITS Exhibits referred to throughout this Provider Manual can be accessed by clicking the respective links below or by visiting EXHIBIT TITLE Exhibit 1 Request for Continuity/Transition of Care Exhibit 2 Your Texas Benefits Medicaid Card Exhibit 3a Community First CHIP Member ID Card Exhibit 3b Community First CHIP Perinate Member ID Card Exhibit

2 3c Community First CHIP Neonate Member ID Card Exhibit 4 Provider Request for Member Transfer Exhibit 5 Request for Increase in 1,500 Capacity Exhibit 6 Texas Standard Prior Authorization Request Form for Health Care Services Exhibit 7 Tuberculosis Report of Case and Patient Services Exhibit 8 American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care Exhibit 9 Sterilization Consent Exhibit 10 Psychological Testing Request Form Exhibit 11 Member Education Request Form Exhibit 12 Medical Record Review Tool Exhibit 13 Member/Client Acknowledgement Statement Exhibit 14 CDC Vaccine Information for Adults

3 Exhibit 15 Consent to Use a Physician Assistant/Nurse Practitioner Exhibit 16 CMS 1500 Claim Form and Instruction Table Exhibit 17 UB 04 Claim Form and Instruction Table Exhibit 18 Private Pay Agreement Exhibit 19 Explanation of Payment (EOP) - Sample CHIP Provider Manual | Community First Health Plans 2 EXHIBIT TITLE Exhibit 20 Provider Complaint Form Exhibit 21 Claim Appeal Submission Form Exhibit 22 Medicaid Eligibility Verification Form (H 1027-A) Exhibit 23 Current Immunization Schedule for Pediatrics Exhibit 24 Blood Lead Screening and Testing Guidelines Exhibit 25 Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Exhibit 26 Provider Billing Guidelines Exhibit 27 Form H3038, Emergency Medical Services Certification CHIP Provider Manual | Community First Health Plans 3 QUICK REFERENCE PHONE LIST CONTACT PHONE NUMBER Member Services Department 1-800-434-2347 (toll-free) (210) 358-6300 Member Services Fax (210)

4 358-6099 Eligibility/Benefits Verification (210) 358-6300 Interpreter Services/Sign Language (210) 358-6300 Population Health Management (210) 358-6050 Preauthorization Fax (210) 358-6040 Urgent Care (210) 227-2347 Behavioral Health Authorization/Care Management (210) 358-6100 (Option 3) 1-800-434-2347 (Option 3) Behavioral Health Fax (210) 358-6387 NICU Fax (210) 358-6388 TTY (For the Deaf and Hard of Hearing) 1-800-390-1175 Provider relations (General Inquiries) Provider relations (Claims Assistance) (210) 358-6294 (210) 358-6030 Claims Information (210) 358-6200 Claims Fax (210) 358-6199 Electronic Claims Availity Payor ID.

5 COMMF Nurse Advice Line (After hour calls are forwarded to Nurse Advice Line) (210) 358-6300 Preventive Health and Disease Management 1-800-434-2347 Community Outreach Agencies (210) 358-6159 Pharmacy-Navitus Health Solutions 1-866-333-2757 Vision Inquiries Envolve Benefit Options 1-800-334-3937 Dental Inquiries DentaQuest MCNA Dental United Healthcare Dental 1- 800-516-0165 1- 800-494-6262 1-877-901-7321 CHIP Provider Manual | Community First Health Plans 4 CHIP Provider Manual | Community First Health Plans 5 TABLE OF CONTENTS EXHIBITS.

6 1 QUICK REFERENCE PHONE LIST .. 3 A. Introduction .. 12 1. Background and Objectives of Program .. 12 2. Role of the CHIP Member Primary Care Provider (PCP) .. 13 3. Role of the CHIP Member Specialty Care Provider .. 16 4. Role of the CHIP Perinate Newborn Primary Care 16 5. Role of the CHIP Perinate Newborn Specialty Care 16 6. Network Limitations .. 17 7. Providers for Members with Disabilities, Children with Special Health Care Needs (CSHCN), and/or Chronic/Complex Conditions.

7 17 8. Role of Pharmacy and Pharmacy Provider .. 18 9. Role of Main Dental Home .. 18 10. How to Help a Member Find Dental Care .. 18 B. CHIP and CHIP Perinate Newborn Covered Services .. 19 1. CHIP Schedule of Benefits .. 19 2. CHIP Perinate Newborn Schedule of Benefits .. 36 3. CHIP and CHIP Perinate Exclusions from Covered Services .. 50 4. Durable Medical Equipment (DME) and Other Products Normally Found in a Pharmacy 52 5. CHIP Pharmacy Program .. 60 6. CHIP and CHIP Perinate Newborn Extra Benefits (Value-Added.)

8 64 Services) .. 64 C. Coordination with Non-CHIP/CHIP Perinate Newborn Covered Services (Non-Capitated Services) .. 68 1. Texas Agency Administered Programs and Case Management Services .. 68 2. Essential Public Health Services .. 68 3. Family Planning 79 4. Access to Telemedicine, Telemonitoring, and Telehealth .. 88 D. Behavioral Health .. 88 1. Behavioral Health Definitions .. 88 CHIP Provider Manual | Community First Health Plans 6 2. Behavioral Health Covered Services.

9 90 3. PCP Requirements for Behavioral Health .. 90 4. Behavioral Health Services .. 91 5. Emergency Behavioral Health Services .. 95 6. Behavioral Health Value-Added Services .. 96 E. Emergency, Urgent, and Routine Care Services .. 96 1. Definitions of Emergency, Urgent, and Routine Care .. 96 2. Emergency Transportation .. 99 3. Member/Client Acknowledgment Statement .. 99 4. Private Pay Form Agreement .. 100 5. Emergency Prescription Supply .. 101 6. Emergency and Non-Emergency Dental Services.

10 102 F. Provider 102 1. Primary Care Provider (Medical Home) Responsibilities .. 102 2. Availability and Accessibility .. 104 3. Plan Termination Process .. 108 4. Member s Right to Designate an OB/GYN .. 109 5. Optometry and Ophthalmology Services .. 110 6. Access to Medication .. 110 7. How to Help a Member Find Dental Care .. 110 8. Advance Directives .. 110 9. Referral to Specialists and Health-Related Services .. 111 10. PCP and Behavioral Health Related Services.