Welcome to Parkland Community Health Plan! At PCHP, we believe in improving every life we touch as good stewards to those we serve.

Need help understanding or reading member information

We have special services for people who have trouble reading, hearing, seeing, or speak a language other than English or Spanish. 
We provide free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, braille, other formats)

We also provide free language services to people whose primary language is not English, such as:

• Qualified interpreters
• Information written in other languages

For financial Literacy information see the Office of Consumer Credit Commission webpage https://occc.texas.gov/consumers/consumer-education/guide

If you need a qualified interpreter, written information in other formats, translation or other services, just call or write Parkland HEALTHfirst Member Services at 1-888-672-2277, KIDSfirst Member Services at 1-888-814-2352, TTY 1-800-735-2989 or mail to:
Parkland Community Health Plan
Attention: Member Services
P.O. Box 569005
Dallas, TX 75356-9005

24-Hour Nurse Line

As a member of Parkland Community Health Plan, you can talk to a nurse when you have health questions. You can call the nurse line 24 hours a day, 7 days a week. English/Spanish/interpreter services are available 24 hours/day, 7 days/week. Even better, this service is provided at no cost to you. The nurse can answer your questions and help you make health decisions. You can call the nurse line at:

Parkland HEALTHfirst      Medicaid STAR              1-888-667-7890 or 214-266-8773
Parkland KIDSfirst          CHIP/CHIP Perinate       1-800-357-3162 or 214-266-8766
For members who are deaf or hard of hearing, you can call us toll-free at 1-800-735-2989.

If you have an emergency, please call 911.

In an emergency

An emergency is when you have a very serious injury or illness. You may be hurt badly, or bleeding heavily. You might be feeling very bad pain or feeling very, very sick. If you don’t get help, you may have permanent damage to a body part or you could even die.

Go to the nearest hospital or call 911 right away when:

• You are afraid you may be dying
• You are badly hurt
• You have very bad chest pains
• You may be poisoned
• You may have taken an overdose of medicine
• You are choking or having problems breathing
• You may have a broken bone
• You have diarrhea or vomiting that won’t stop
• You are bleeding heavily
• You  are badly burned
• You fainted
• You suddenly can’t move (paralysis)
• You are a victim of a violent attack (rape, mugging, stab or gunshot wound)
• You have thoughts of causing harm to yourself or others
• You are about to deliver a baby

For many illnesses, you don’t need to go to the emergency room.  If you have a cold, a cough or a rash, you can call your doctor. It’s the same if you have small cuts or bruises. You don’t need to go to the hospital.  If you’re unsure, you can call our nurse line. The nurse can help you decide if you need to go to the emergency room.

Nurse line - you can talk to a nurse when you have health questions. You can call the nurse line 24 hours a day, 7 days a week.

Parkland HEALTHfirst
Member Services - 1-888-672-2277
Parkland 24-hour Nurse Line: 1-888-667-7890 or 214-266-8773

Parkland KIDSfirst
Member Services - 1-888-814-2352
Parkland 24-hour Nurse Line: 1-800-357-3162 or 214-266-8766

If you feel that you can wait to seek care, you can call your primary care provider.

Behavioral Health Hotline

Our health plan covers health for our members as a whole person. That includes help for mental health problems like depression or substance abuse. You can access behavioral health care on your own without a referral.

For HEALTHfirst Behavioral Health Services Hotline 
(Includes mental health & substance abuse, English/Spanish/interpreter services available 24 hours/day, 7 days/week)
Call 1-800-945-4644 (toll-free).

For KIDSfirst Behavioral Health Services Hotline 
(Includes mental health & substance abuse, English/Spanish/interpreter services available 24 hours/day, 7 days/week) 

CHIP: call Beacon at 1-800-945-4644 (toll-free)
CHIP Perinate Newborn:  Call Member Services at 1-888-814-2352

For emergencies call 911.

 

Report Fraud, Waste and Abuse

If you suspect a client (a person who receives benefits) or a provider (e.g., doctor, dentist, counselor, etc.) has committed waste, abuse or fraud, you have a responsibility and a right to report it. To report waste, abuse or fraud, gather as much information as possible and report providers or clients directly to:

Parkland Community Health Plan
Attention: SIU Analyst
P. O. Box 569005
Dallas, TX 75356-9005
1-866-519-0916

If you have access to the internet, click on HHSC OIG and choose “Reporting Waste, Abuse and Fraud”. The site provides information on the types of waste, abuse and fraud to report providers or clients.

If you do not have Internet access and prefer to talk to a person, call the Office of Inspector General (OIG) Fraud Hotline at 1-800-436-6184, or you may send a written statement to the OIG addresses:

Office of Inspector General
Medicaid Provider Integrity/Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200

When reporting a provider (e.g., doctor, dentist, counselor, etc.) provide the following:

• Name, address, and phone number of provider;
• Name and address of the facility (hospital, nursing home, home health agency, etc.);
• Medicaid number of the provider and facility is helpful;
• Type of provider (physician, physical therapist, pharmacist, etc.);
• Names and the number of other witnesses who can aide in the investigation;
• Dates of events; and
• Summary of what happened.

To report clients, use this address:
Office of Inspector General
General Investigations/Mail Code 1362
P.O. Box 85200
Austin, TX 78708-5200
HHSC OIG to report fraud

Provider Relations Contact Information

Contact Provider Relations for important details about our clinical programs and guidelines as well as resources to assist you with coding, billing practices, and improving patient care quality.

Provider Relations Hotlines:
Parkland HEALTHfirst     Medicaid STAR            1-888-672-2277
Parkland KIDSfirst         CHIP/CHIP Perinate     1-888-814-2352

Provider Call Center – Our hours of operation for the provider hotline is Monday through Friday, 8:00 a.m. to 5:00 p.m. Central time, excluding State-approved holidays.  After hours or weekends, please leave a message. Providers also have 24/7/365 day access by utilizing self-service tools such as our interactive voice response (IVR) system and provider portal for eligibility and benefit questions.

Email: TXProviderEnrollment@aetna.com

Provider Relations Department

How to request a fair hearing

After you have gone through all of Parkland Healthfirst’s appeals process, a Fair Hearing can be requested within 150 days from the appeal decision letter. The Appeal denial notification includes a Fair Hearing Request Form (English /Spanish) for the member to complete and send to the health plan.

In the instance the MCO does not make a decision on an appeal within the 30-calendar day timeframe, the member may request a state fair hearing within 150 days from the date that is 30 days after the appeal request date.

Procedures for requesting a fair hearing

If a member or as the parent or guardian of a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a signed authorization letter to the health plan telling them:

• The representative’s name
• The representative’s title
• The representative’s agency
• The representative’s address
• The representative’s phone number

A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 150 calendar days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 150 calendar days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at: Parkland Healthfirst Attention: Member Advocate P.O. Box 569005 Dallas, TX 75356-9005 or 1-888-672-2277 or by fax (877-223-4580). If you do not request a fair hearing by this date, the service the health plan denied will be stopped.

You have the right to continue to receive services the health plan denied or reduced, at least until the final hearing decision if member requests a state fair hearing within: (1) 30 calendar days from Parkland Community Health Plan’s mailing of the Notice of Action.  The member may be required to pay the cost of services furnished while the appeal is pending if the final decision is adverse to the member.  A decision on a state fair hearing will be made in 120 days (for State Fair Hearing Requests through October 23,2020).

Who can I call to request a fair hearing

Parkland Healthfirst - 1-888-672-2277

Toll-free number to request an Appeal or Fair Hearing

Mailing address for written request for fair hearing

Parkland Healthfirst

Attention: Member Advocate

P.O. Box 569005

Dallas, TX 75356‑9005

Contact number: Toll-free number to request an Appeal or Fair Hearing

Parkland Healthfirst - 1-888-672-2277

Pharmacy Prior Authorization

Parkland Community Health Plan, Inc contracts with Navitus Health Solutions (http://www.navitus.com/ - 1-877-908-6023, to manage pharmacy network.  The information for clinical edits for covered drugs, Drugs requiring prior authorization, Prior authorization criteria logic, Supporting tables, References, and Publication History. 

For prior authorization requests, see numbers below or fax the pharmacy authorization form. Providers must download the form Pharmacy - Texas Standard Prior Authorization Request  and click Here and obtain the appropriate drug criteria from the Vendor Drug Program (VDP) website. The forms can be faxed to the number below.

Parkland has a single sign on for all Texas Medicaid and CHIP clinical edits. All Clinical edits are updated as required and managed appropriately.

Clinical Edits are now at this address:

https://txstarchip.navitus.com/pages/clinical-edits.aspx

PA forms (STAR/CHIP):

https://txstarchip.navitus.com/pages/prior-authorization-forms.aspx

Formularies (STAR/CHIP):

https://txstarchip.navitus.com/pages/formulary.aspx

Synagis info:

https://txstarchip.navitus.com/pages/synagis.aspx

Phone numbers:

Navitus (Pharmacy)

1-877-908-6023

BIN# 610602 Claim PCN: MCD STAR Claim Group – PHS and CHIP Claim Group – PHC

Prior Auth Fax

920-735-5312

Important Phone Numbers

Important Phone Numbers for Parkland Community Health Plan (Pharmacy, Vision, Dental, Behavioral Health and Transportation).

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