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CHIP Perinatal

Provider Manual

The following documents are provided in Adobe PDF format.
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2009 CHIP Peri Provider Manual (02-13-09 including exhibits 35mb)
2009 CHIP Perinate Provider Manual (02-13-09 without exhibits 965K)

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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