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CHIP Perinatal

Provider Manual

The following documents are provided in Adobe PDF format.
Click to Get Acrobat Reader Free! If you do not have Acrobat Reader, it is available free for Mac & PC at Adobe's website. Simply select the correct version for your particular computer and follow the directions provided. PDF files retain all document formatting, insuring the copy you get when you print the file will be the same as the one you would get from our office.

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Provider Manual (September 2015) (without exhibits)
Exhibit 01 - Request for Continuity - Transition of Care
Exhibit 02 - Authorization List
Exhibit 03 - Provider Office Assessment Tool
Exhibit 04 - Physician Medical Records Audit Tool
Exhibit 05 - Pediatric Preventive Care Recommendations
Exhibit 06 - Texas Referral Authorization Form
Exhibit 07 - Provider Complaint Form
Exhibit 08 - Provider Appeal Form
Exhibit 09 - TB Report of Case and Patient Services
Exhibit 10 - TB Report Follow-Up
Exhibit 11 - TB Case Report
Exhibit 12 - Member Education Request Form
Exhibit 13 - Children with Complex Special Health Care Needs Form
Exhibit 14 - Provider Request for Transfer
Exhibit 15 - Texas Vaccine for Children Forms
Exhibit 16 - Behavioral Health Authorization Request
Exhibit 17 - Psychological Testing Request Form
Exhibit 18 - Behavioral Health Report to PCP
Exhibit 19 - Appeal Submission Form
Exhibit 20 - Emergency Medical Services Certification - Form 3038
Exhibit 21 - CMSHCFA-1500
Exhibit 22 - UB-04
Exhibit 23 - Explanation of Payment (EOP)
Exhibit 24 - CHIP Perinatal Sample Member ID Card (MOM)
Exhibit 25 - CHIP Perinatal Sample Member ID Card (Newborn)
Exhibit 26 - Report of Pregnancy
Exhibit 27 - Private Pay Agreement
Exhibit 28 - Member-Client Acknowledgement Statement
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