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El Paso First Quarterly Provider Meeting
Wednesday November 11, 2009
El Paso First Team
Frank Dominguez – Director, Provider Relations and ContractingIrma Herrera – Supervisor, Provider RelationsCynthia Moreno – Provider Relations RepresentativeRene Duran – Provider Relations RepresentativeMichelle Anguiano – Provider Relations THSteps CoordinatorEva Ortiz – Provider Relations RepresentativeEvelyn Lopez– Contracting Representative Cindy Avalos – Contracting RepresentativeJim Voiland – Health Services DirectorEdgar Martinez– Member Services DirectorLluvia Acuna – Migrant Outreach CoordinatorSonia Lopez – Claims DirectorCorina Diaz – Complaint and Appeals Specialist
EL Paso First Health Plans, Inc.
WE ARE MOVING! – DECEMBER 18, 2009! Our new address is:
1145 Westmoreland DriveEl Paso, TX 79925-5615
Please note:Paper Claim submissions will continue to go to:
El Paso First Health Plans - ClaimsP.O. Box 971370
El Paso, X 79997-1370Our General Correspondence address will not change.
P.O. Box 971100El Paso, TX 79997-1100
After the move all Complaints and Appeals will be sent to the new address.
Until that time, please send complaints and appeals to our current address to the attention of the Complaints and Appeals Specialist, as stated in your provider manual.
We look forward to welcoming you at our new home!
NEW LOCATION
Health Services Department
Jim VoilandHealth Services Director
Alberto N. Hawkins Settlement Update:
Time frame for response on authorizations changed to:
7 day wait period for requested information (previous 10 day)
Phototherapy Changes (In-Home)Phototherapy changes for in home use – for low-risk newborns which are defined as 35 wk gestation at birth (changed from 38 wks gestation) without co morbidity. New total serum bilirubin levels. All requests must include:
1. THSteps-CCP Prior Authorization Request Form (page B-108 in the Tx Medicaid manual)
2. El Paso First Health Plans prior authorization request.
(10/09/09 through 10/30/09) *****Attention All Medicaid Providers*****Effective for dates of service on or after November 1, 2009, benefit criteria for phototherapy
devices will change for Texas Medicaid. Details of these changes are available on the TMHP website at www.tmhp.com for more
information, call the TMHP Contact Center at 1-800-925-9126.
Reminder – medium and high risk newborns – phototherapy is not a covered benefit for home use.
Providers MUST submit documentation to support medical necessity
Michelle Anguiano THSteps Coordinator
Provider Relations Department
THSteps Updates
Periodicity Schedule Effective September 1, 2009
Checkups need to be done at these ages:
3-5 days, 12 months 3 years 9 years 15 years
1-2 weeks, 15 months 4 years 10 years 16 years
2 months, 18months 5 years 11 years 17 years
4 months, 24 months 6 years 12 years 18 years
6 months, 30 months 7 years 13 years 19 years
9 months 2 years 8 years 14 years 20 years
ASQ and PEDS Screening ToolsThese screening tools will become mandatory in
2011.
If purchased and used now providers will receive an additional reimbursement.
Through August 31, 2011, providers may choose to use a standardized screening tool that is not listed in the Required Screening Ages and Tools table to complete the requirements of a medical checkup visit; however, providers may not submit a claim for a tool that is not listed in the following table.
Links for these tools are available at http://www.epfirst.com/ProvidersEPSTD.html
Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Change http://www.tmhp.com/txtlstvw.aspx?LstID=b48ca997-4760-4d81-9401-5f92a493dd5d
Mental Health Screening ToolsShould be used at these ages:
0-2 years, 3-9 years, 10-12 years, and 13-20 years
Can be found at http://www.epfirst.com/ProvidersEPSTD.html under THSteps Mental Health Screening Tools
El Paso First’s Behavioral Unit can assist you by locating mental health and social services for your patients.
Contact the Behavioral Unit at 915-532-3778 ext 1500
OEFV Updates
Oral Evaluation and Fluoride Varnish Program and the First Dental Home Initiative trainings at EPCC Nov 5 and 6.
OEFV upcoming webinar: November 18, 2009. To register please go to: http://www.dshs.state.tx.us/dental/OEFV_Training.shtm
Contact InformationIf you have any questions or concerns please contact me at:
E-mail: [email protected] Phone: (915)298-7198 extension 1053.
Member Services Department
Edgar MartinezMember Services Director
Texas Health Steps Exams
How do you know when a member is due for a THSteps exam:
Their 3087 will state that they are due
Member’s due are listed on your Provider Roster
Call El Paso First to verify if the member is due for a THSteps exam at (915) 532-3778 or 1-877-532-3778
El Paso First Premier Plan (Medicaid)
•$15 Welcome packet with OTC medications. •Preventive Dental Services for pregnant members over 21 years of age.•Eyeglasses valued up to $125•Free Transportation for medical appointments.•Additional nutritional counseling services for members under 21 years of age.•Additional Behavioral Health services.
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El Paso First CHIP Plan (CHIP)
•$15 Welcome packet with OTC medications. •Preventive Dental Services for pregnant members under 19 years of age.•Additional 25% discount toward the purchase of lenses and frames•Additional 20% discount toward the purchase of disposable contact lenses. •Free Transportation for medical appointments.•Additional nutritional counseling services for members under 19 years of age.
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El Paso First CHIP Perinatal Plan (CHIP Perinatal)
•$15 Welcome packet with OTC medications. •Free Transportation for medical appointments.
Texas Health Steps Exams
How do you know when a member is due for a THSteps exam:
• Their 3087 will state that they are due• Member’s due are listed on your Provider
Roster• Call El Paso First to verify if the member is
due for a THSteps exam. (915) 532-3778 or 1-877-532-3778
3087 Form (Managed Care Medicaid) – Texas Health Steps Exams
3087 Form (Traditional Medicaid) – Texas Health Steps Exams
STAR Provider Roster That Includes When Texas Heath Steps Medical Exams Are Due
Texas Health Steps Exams
El Paso First provides: • Assistance to the member to schedule a THSteps exam
with their PCP. • Accelerated THSteps medical services for migrant
members• Transportation arrangements for members that are due a
THSteps exam (Taxi rides)• Telephone reminder calls to the members that they are
due a THSteps exam.• Mail a reminder “Happy Birthday” card to the member that
is due a THSteps exam.
Texas Health Steps
• A child’s check up must be done no later than 90 days after his or her birthday.
Texas Health Steps
• A child’s check up must be done no later than 90 days after his or her birthday.
A seasonal farm worker is a person who works on farms, in fields or as a food packer during certain times of the year. Seasonal farm workers move to different places to
follow the crops.
Do you assist any Seasonal Farm Workers?
El Paso First has special Medicaid services for children of seasonal farm workers:•We help schedule THSteps Medical Checkups appointments•Assist with accelerated THSteps medical services for migrant members•Vision Benefits•Mental Health Services•Night Clinics•Transportation
Dear member, let us help you:
El Paso First Premier Plan has special Medicaidservices for the children of seasonal farm workers and we
would like to know the following:
• Are you a seasonal worker?Yes No
• Picking onions, chile, lettuce, tomatoes, grapes,pecans, etc…?
Yes No• Packing or processing vegetables, fruits, fish,
chicken, etc…?Yes No
• In dairies, fisheries, or slaughtering, etc…?Yes No
If you answered YES to any of these questions,please contact Lluvia Acuña, Migrant Coordinatorat (915) 532-3778. We will help you receiveaccelerated services. Thank you for your time!
Questionnaire/ Cuestionario
Estimado miembro, permítanos ayudarle:
El Plan Premier de El Paso First tiene serviciosespeciales de Medicaid para niños de
trabajadorestemporales del campo, por eso nos gustaría
saberlo siguiente:
• ¿Es usted un trabajador temporal del campo?
Si No• ¿En la pizca de cebolla, chile, lechuga,
tomate,uvas, nueces, etc…?
Si No• ¿Empacando o procesando vegetales, frutas,
pescado, pollo, etc…?Si No
• ¿En lecherias, pesca, o matanza, etc…?Si No
Si contesto SI a alguna de las preguntas, porfavor comuniquese con Lluvia Acuña,
CoordinadoraMigrante, al (915) 532-3778. Le ayudaremos arecibir servicios rápidos. ¡Gracias por su tiempo!
Lluvia AcuñaMigrant Outreach Coordinator
(915) 532-3778 ext. 1075
Laura Caldelas Outreach Supervisor
(915) 532-3778 ext. 1108
Contact Information
Member Services Department
Questions?
For more information please contact us at 915-532-3778 or visit our web site at www.epfirst.com
Compliance Department
Rocio Chavez - Compliance DirectorCorina Diaz – Complaints and Appeals Specialist
How to Complain?
All complaints must be in writing and mailed attention to Complaint and Appeals.
What should be included in your complaint?
Note: Adverse Determination complaints or appeals should be addressed attention Health Services Department.
What is a Complaint?
AcknowledgementResolution
What is a level 1 Appeal?
What is a level 2 Appeal?
Corrected Claims?
Claims Department
Sonia LopezClaims Director
Claims Guidelines• The provider must send electronic claims in a American
National Standard Interchange (ANSI) 837P/837I format.
• The provider must be sending CMS 1500 (Professional) claims.
• Facility must be send UB04 (Hospital) claims.
(Faxed copies will be accepted only if an original is on file for the DOS in inquiry.)
CMS 1500
CMS 1450 UBO4
Claim Verification
• Clean Claim Edits
• NPI Verification for Rendering and Referring Provider
Claim Notification Form
Additional Information Rejection Form
H1N1 Reimbursement To Submit Vaccine:
•Administration procedure code 90465, 90466, 90471, or 90472, 90470.
•flu vaccine procedure code 90663, which will process as informational only.
Questions?
El Paso First wishes you a joyful holiday season and
a memorable new year 2010! Thank you for the
great service you provide to our members!
