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Details the roles and responsibilities of primary care, specialty care, pharmacy, and dental home, including medical record standards, HIPAA-related provisions, and network limitations. Provides sections on behavioral health coordination, quality management and clinical practice guidelines, and complete billing and claims processes including submission timelines, capitation services, appeals, and helpful sample forms.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/texas-childrens-health-plan-provider-manual-provider-and-care-coordination/269177/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/texas-childrens-health-plan-provider-manual-provider-and-care-coordination/269177.png","ImageObject",300,407,{"name":92,"@type":93},"Mack Lee","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-15",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is covered in the Quick Reference Phone List section of the Provider Manual?","Question",{"text":112,"@type":113},"It lists Texas Children’s Health Plan phone numbers and contact numbers for other organizations to support provider communication and coordination.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What responsibilities are outlined for primary care providers in this manual?",{"text":117,"@type":113},"The manual defines the primary care role as a medical home and details primary care provider responsibilities, including record standards and coordination expectations.",{"name":119,"@type":110,"acceptedAnswer":120},"How does the manual guide billing and claims handling?",{"text":121,"@type":113},"It describes claims submission, capitation services, emergency claims, submission time limits, clean claims payment, out-of-network payments, filing steps, and claims appeals.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},269177,1789447761,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":129,"read_time":144},1236954509970,"https://us-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Texas Children’s Health Plan Provider Manual  \nSTAR/Medicaid Children’s Health  \nInsurance Program (CHIP)  \nAustin Hardin Matagorda San Jacinto Austin Hardin Matagorda San Jacinto  \nBrazoria Harris Montgomery Tyler Brazoria Harris Montgomery Tyler  \nChambers Jasper Newton Walker Chambers Jasper Newton Walker  \nFort Bend Jefferson Orange Waller Fort Bend Jefferson Orange Waller  \nGalveston Liberty Polk Wharton Galveston Liberty Polk Wharton  \nND-0113-074 03-2015  \n Texas Children’s Health Plan Provider [and Care Coordination | 832-828-1008 | TexasChildrensHealthPlan.org](and Care Coordination | 832-828-1008 | TexasChildrensHealthPlan.org)   \nTable of Contents  \nI. QUICK REFERENCE PHONE LIST................................................. 10  \nTexas Children’s Health Plan Phone Numbers .............................................................................. 10  \nTelephone Numbers for Other Organizations............................................................................... 11  \nII. INTRODUCTION............................................................................... 12  \nTexas Children’s Health Plan Overview ........................................................................................ 12  \nProducts ....................................................................................................................................... 12  \nUsing the Provider Manual........................................................................................................... 12  \nHealth Insurance Portability and Accountability Act of 1996 ....................................................... 13  \nStandards for Medical Records ..................................................................................................... 14  \nRole of a Primary Care Provider (Medical Home) ........................................................................ 16  \nPrimary Care Provider Responsibilities ......................................................................................... 17  \nRole of a Specialty Care Provider .................................................................................................. 19  \nNetwork Limitations .................................................................................................................... 19  \nRole of Pharmacy .........................................................................................................................20  \nRole of Main Dental Home..........................................................................................................20  \nIII. BEHAVIORAL HEALTH ..................................................................... 21  \nDefinition of Behavioral Health ................................................................................................... 21  \nPrimary Care Provider Requirements for Behavioral Health ......................................................... 21  \nBehavioral Health Services ...........................................................................................................22  \nSubstance Use Disorder Treatment Benefits ..................................................................................24  \nCoordination Between Behavioral Health and Physical Health Services .......................................25  \nBehavioral Health Focus Studies and Utilization Management Reporting ....................................26  \nIV. QUALITY MANAGEMENT................................................................ 27  \nQuality Improvement Program Overview..................................................................................... 27  \nClinical Practice Guidelines.......................................................................................................... 27  \nQuality Improvement Projects......................................................................................................28  \nV. BILLING AND CLAIMS......................................","cbCainIiANnBti1Z","https://ap.wps.com/l/cbCainIiANnBti1Z","pdf",11883101,192,"English","# Quick Reference Phone List\n## Texas Children’s Health Plan Phone Numbers\n## Telephone Numbers for Other Organizations\n# Introduction\n## Texas Children’s Health Plan Overview\n## Products\n## Using the Provider Manual\n## Health Insurance Portability and Accountability Act of 1996\n## Standards for Medical Records\n## Role of a Primary Care Provider (Medical Home)\n## Primary Care Provider Responsibilities\n## Role of a Specialty Care Provider\n## Network Limitations\n## Role of Pharmacy\n## Role of Main Dental Home\n# Behavioral Health\n## Definition of Behavioral Health\n## Primary Care Provider Requirements for Behavioral Health\n## Behavioral Health Services\n## Substance Use Disorder Treatment Benefits\n## Coordination Between Behavioral Health and Physical Health Services\n## Behavioral Health Focus Studies and Utilization Management Reporting\n# Quality Management\n## Quality Improvement Program Overview\n## Clinical Practice Guidelines\n## Quality Improvement Projects\n# Billing and Claims\n## Claims Submission\n## Monthly Capitation Services\n## Emergency Services Claims\n## Time Limit for Submission of Claims\n## Clean Claims Payment\n## Out-of-Network Provider Payments\n## Claims Filing\n## Claims Questions/Status\n## Claims Appeals\n# Helpful Forms\n## Sample Form UB-04\n## Sample Form HCFA 1500\n## Claim Appeal/Resubmission Form\n## Prior Authorization Request Form","[{\"question\":\"What is covered in the Quick Reference Phone List section of the Provider Manual?\",\"answer\":\"It lists Texas Children’s Health Plan phone numbers and contact numbers for other organizations to support provider communication and coordination.\"},{\"question\":\"What responsibilities are outlined for primary care providers in this manual?\",\"answer\":\"The manual defines the primary care role as a medical home and details primary care provider responsibilities, including record standards and coordination expectations.\"},{\"question\":\"How does the manual guide billing and claims handling?\",\"answer\":\"It describes claims submission, capitation services, emergency claims, submission time limits, clean claims payment, out-of-network payments, filing steps, and claims appeals.\"}]","Texas Children’s Health Plan Provider Manual - Provider and Care Coordination | PDF",484]