A Service Coordinator is the central contact between Texas Children’s Health Plan and a member’s providers and family members. The purpose of a Service Coordinator is to maximize a Member’s health, wellbeing and independence. The Service Coordinator must work with the Member’s PCP to coordinate all of a member’s health services. The STAR Kids Service Coordinator also engages as an advocate and intervenes on behalf of the member if approved by the member. The Service Coordinator will perform an overall [...]
The American Academy of Pediatrics (AAP) has recently released a Clinical Report strongly advising against codeine use in children. The rationale of the AAP is as follows: “Codeine is a prodrug with little inherent pharmacologic activity and must be metabolized in the liver into morphine, which is responsible for codeine’s analgesic effects. However, there is substantial genetic variability in the activity of the responsible hepatic enzyme, CYP2D6, and, as a consequence, individual patient response to codeine varies from no effect [...]
Vaccination Flu season is back and vaccinating continues to be the best way to protect ourselves and our patients against serious complications from the flu. Patients should only receive the intramuscular vaccine; intranasal flu vaccine is not effective for the 2016-2017 flu season.1 Patients 17 and younger should be offered the flu vaccine during office visits, while those 18 years and older also have the option of receiving it at pharmacies. Treatment (Antiviral and Supportive) Patients who are high risk for complications [...]
Effective January 1, 2017, Texas Children’s Health Plan will reimburse providers for maternal depression screening conducted at a well-child visit. Postpartum depression screening utilizing the Edinburgh Postnatal Depression Scale may be reimbursed up to 2 times per member ages 0-6 months, using CPT code 96161. Code 96161 is used to report the use of a standardized instrument to screen for health risks in the caregiver for the benefit of the patient. The reimbursement for this code will be based [...]
Effective February 1, 2017 Texas Children's Health Plan will require prior authorization on all sleep studies in children ages 18 and under. Claims for services on or after February 1, 2017 will be denied if no authorization is present. Please contact Texas Children's Health Plan Provider Relations at 1-800-731-8527, or visit the Texas Children's Health Plan Provider portal at http://www.tchp.us/for-providers for a copy of the guidelines utilized to determine medical necessity for sleep studies in children.
HEDIS stands for Healthcare Effectiveness Data and Information Set. It is a widely used set of performance measures by the nation’s health plans, and an essential tool in ensuring that our members are getting the best healthcare possible. It is extremely important that our providers understand the HEDIS® specifications and guidelines. In this section of The Checkup we will highlight different HEDIS metrics. We will provide a description of the measures, the correct billing codes to support services rendered [...]