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El Paso First Quarterly Provider Meeting. Thursday, August 27, 2009. El Paso First Team. Frank Dominguez – Director, Provider Relations and Contracting Irma Herrera – Supervisor, Provider Relations Cynthia Moreno – Provider Relations Representative - PowerPoint PPT Presentation
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El Paso First Quarterly Provider Meeting
Thursday, August 27, 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 DirectorMonica Esparza – Member Services SupervisorLluvia Acuna – Migrant Outreach CoordinatorSonia Lopez – Claims Director
El Paso First Contact Information
Cindy AvalosProvider Relations Representative
El Paso First Departments Contact InformationMain number: 915-532-3778
DepartmentDepartment ExtensionExtension Fax numberFax number DescriptionDescription
Member ServicesProvider
Assistance
STAR -1514CHIP – 1517HCO – 1502TPA - 1529
915-532-2286 Eligibility, enrollment, outreach events, migrant farm workers
Health Services 1500 915-298-7866(pre-authorizations)
915-298-7870(credentialing)
Pre-authorizations, case management, and credentialing
Provider Relations
1507 915-532-2877 Provider contracts, address changes, general concerns
Claims & PCU PCU-1504CHIP-1512STAR-1527TPA-1509
915-298-7867 Claims status, corrections,and reports
Page 1
In order to properly assist you before calling please have the following information ready:
• Let us know that you are a Provider • Let us know what Department you are trying to
reach• Let us know if you are calling to verify eligibility
and for what program (STAR, CHIP, HCO or Preferred Administrators)
Health Services Department
Jim VoilandHealth Services Director
TP-1 and TP-2 Forms For initial therapy request the Provider must
submit a request for “Initial Outpatient Therapy (Form TP-1)” that is signed and dated by the therapist and physician.
For extension of the therapy request the Provider must submit a “Request for Extension of Outpatient Therapy (Form TP-2)” that is signed and dated by the therapist and physician.
All physician and provider signatures on the TP-1 and TP-2 forms, physician orders, and other documentation must be current, unaltered, original, handwritten, and dated. Computerized or stamped signatures and dates are not accepted.
Michelle Anguiano THSteps Coordinator
Provider Relations Department
THSteps Updates
THSteps Policy ChangesOn July 31, 2009 HHSC conducted the Medicaid Provider Responsibilities Workshop. The following changes are effective September 1, 2009:
There are four new ages added to the periodicity schedule: 3-5 days, 30 months, 7 and 9 years.
FQHCs and RHCs cannot submit a claims for a medical checkup encounter unless completed by the physician, advanced practice nurse, or physician’s assistant. The RN may assist in the completion, but the unclothed physical must be performed by the physician, APN or PA. Lab specimens for glucose, hyperlipidemia, syphilis, and HIV
related testing may go to the laboratory of the provider’s choice due to CLIA regulations regarding shipping of specimens.
THSteps Policy Changes cont.Screening Ages Developmental Screening
•9 to 30 months providers need to use the ASQ or PEDS.•3-4 years ASQ-SE or PEDS.•Reimbursement will be considered only if the tools above are completed.
Use of other tools will be allowed to meet the requirement for the next 2 years but will not be reimbursed. At the end of the two year transition, checkups without the ASQ,
ASQ-SE or PEDS will not be considered complete checkups.
Online Provider Education Requirements
Effective July 1, 2009 as per the Frew v. Hawkins’ Corrective Action Order: Healthcare Provider Training, HHSC must recognize Medicaid enrolled health care providers who complete training on Frew and/or Texas Health Steps related topics.
Health Plans will require their health care providers to take the training modules available through the DSHS Online Provider Education located on the DSHS website at http://www.txhealthsteps.com
Online Education Continued……All EPSDT Providers who have their own practice or belong to a group are required to complete the Online Modules. Additional information may be found on the website. You can also access this link at the El Paso First website by clicking at http://www.epfirst.com/ProvidersEPSTD.html and selecting THSteps Online Provider Education.
Your STAR contract will not be amended, however, we are requesting for you to please attach the letter we mailed you to Section 4 of your El Paso First Provider Manual under Statutory Requirements on page 80.
Oral Evaluation and Fluoride Varnish Program Updates
Upcoming WebinarsFor more information please log in to:
http://www.dshs.state.tx.us/dental/OEFV_Training.shtm
Resources to help you
Transportation Provider Rosters THSteps Members Due Only Lists Birthday Reminder Postcard Outbound calls
Contact Information
If 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
3087 Form (Traditional Medicaid) – Texas Health Steps Exams
3087 Form (Managed Care Medicaid) – Texas Health Steps Exams
STAR Provider Roster IncludesWhen THSteps Medical Exams Are Due
El Paso First Provides the following assistance for Texas Health Steps Exams 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 Happy Birthday Reminder Post Card• A child’s check up must be done no later
than 90 days after his or her birthday.
El Paso First THSteps Incentive
• A child’s check up must be done no later than 90 days after his or her birthday.
Missed Appointment Referral Service was created to help:
Reduce the number of missed appointments
Assist provider office staff with the issues missed appointments may create.
THSteps Missed Appointment Referrals
THSteps Missed Appointment Referral Form
Texas Health Steps Outreach and Informing Staff will:
Contact the referred recipient by phone call or home visit to provide appropriate assistance.
Will notify the provider of the results.
THSteps Missed Appointment Referrals Outreach
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
Claims Department
Sonia LopezClaims Director
EPFIRST Claim Processing Days
0
5
10
15
20
25
30
35
40
Avg Days to Pay
Avg Days to Adjudicate
WHO MAKES IT HAPPEN
Claims Department Leadership Contacts
Provider Care Unit (PCU) Have claims inquiries? Meet our top notch PCU team providing you assistance with your claims inquiriesMeet our top notch PCU team providing you assistance with your claims inquiries
PCU is here for you……..only a phone call away...... Contact us at 532-3778When calling PCU a Claims Specialist will:
– Give you claim status.
– Resolve or answer claim questions.
– Answer Electronic claims submission rejections or questions.
– Assist with claims disputes.
Claim Formal AppealsYou have the right to appeal any disposition of a
claim through a formal appeal. Simply submit your formal appeal in writing to our
Complaints and Appeal Department within 120 days from the date of your Remittance Advice (RA) to the following address:
El Paso First Health Plans, Inc.Attn: Complaints and Appeals Department PO BOX 971370, El Paso, Texas 79997-1370
Understanding your Remittance
Advice (RA)
PROVIDER REMITTANCE ADVICE (RA)
Remittance Advice (RA)
American DoctorsP O BOX 123
El Paso, Tx 79999
Claim Number Assignment
Julian Year Julian Date Alpha Letter Claim No. Reversal/Adjustment
08 017 Y 00136 ( R ) or ( A )
•Claim Number: 08017Y00136 •Claim Number Reversal : 08017Y00136R1•Claim Number Adjustment: 08017Y00136A1
•Alpha Letters: (A thru Z) Manually Entered Claims•Alpha Letter: ( E ) Electronic Imported Claims•Numeric: ( 5) Portal Entered Claim
Reason TotalDuplicate Claim 12,788
Claim Submission Window Exceeded
Members has no enrollment
12,133
9,322
Member has SSI Coverage SSI
NPI Number Not Attested
Benefit Requires Authorization
7,075
2,795
2,913
EP First Top Denials
Questions?
Thank you for your attendance!
