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El Paso First Health Plans SUD Provider Training Presentation. Thursday August 19, 2010. El Paso First Team. Provider Relations Department Frank Dominguez – Director, Provider Relations and Contracting Michelle Anguiano – Provider Relations THSteps Coordinator

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El Paso First Health Plans

SUD Provider Training Presentation

Thursday August 19, 2010


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El Paso First Team

  • Provider Relations Department

  • Frank Dominguez – Director, Provider Relations and Contracting

  • Michelle Anguiano – Provider Relations THSteps Coordinator

  • Health Services Department

  • Jim Voiland, MBA, MSN, RN– Health Services Director

  • Janel Lujan, LMSW– Case Management Coordinator

  • Claims Department

  • Sonia Lopez – Claims Director


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Agenda

  • Provider Relations Overview

  • Healthx Fax System

  • Substance Abuse Treatment Benefits

  • Provider Care Unit (PCU)

  • Claim Submission and Appeal Process

  • Q/A


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Provider Relations Department

Provider Relations Overview


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Provider Relations and Contracting Department

  • Liaison Between Network Providers, Health Plan and State Regulators (HHSC and TDI)

  • Network Development (Recruitment)

  • Provider Education

Call 915-225-5463

Eligibility Verification

Claims Information

Authorization Information

24 hours a day 7 days a week

Third Party Administrator Commercial Plan

STAR/Premier Plan

CHIP and

CHIP Perinate

Health Care Options Indigent Program


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Call 915-225-5463

Eligibility Verification

Claims Information

Authorization Information

24 hours a day 7 days a week

STAR/Premier Plan, CHIP and CHIP Perinate


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EL Paso First Website

El Paso First Website: www.epfirst.com

Provider Relations Hotline: 915-532-3778 ext 1507

  • Access Provider Manual, Provider Directories and Forms

  • Provider Newsletter

  • Provider Forms (Authorization List, Demographic Update, etc.)

  • LinksWaste, Abuse and Fraud Educational LinkTMHP Provider Procedures ManualCHIP, STAR, and CHIP Perinate Provider ManualCHIP Health Benefit Plan-Evidence of CoverageCHIP Perinatal Program for Unborn Children-Evidence of Coverage

Call 915-225-5463

Eligibility Verification

Claims Information

Authorization Information

24 hours a day 7 days a week

Third Party Administrator Commercial Plan

STAR/Premier Plan

CHIP and

CHIP Perinate

Health Care Options Indigent Program



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Questions?

Thank You!!!


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Health Services Department

Substance Abuse Treatment

Benefits


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Pre-Authorization Overview

  • Substance use treatment services

  • Pre-authorization requirements

  • Behavioral health pre-certification form

  • Frequently asked questions

  • Case management

  • El Paso First crisis line


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Substance Use Treatment Services

  • Outpatient substance abuse treatment services will become effective September 1, 2010.

    • assessment

    • ambulatory detoxification

    • counseling

    • medication assisted therapy

  • Residential benefits will become effective January 2011 (pending federal government approval).

    • Residential detoxification and treatment


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Pre-Authorization Requirements

  • Initial evaluations do not require an authorization

  • Subsequent visits require an authorization

  • Behavioral Health Unit will process authorizations within 72 hours


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Substance Use Benefits Available September 1, 2010

  • Assessment

    • Billing code: H0001

    • Does not require prior authorization

  • Outpatient individual counseling

    • Billing code: 9-H0004

    • Requires prior authorization

  • Outpatient group counseling

    • Billing code: 9-H0005

    • Requires prior authorization

  • Ambulatory (outpatient) detoxification

    • Billing code: 1-H0014

    • Requires prior authorization


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Substance Use Benefits Available September 1, 2010

  • Medication Assisted Therapy (MAT)

    • MAT for opioid addiction when using methadone

      • Billing code: 1-H0020

      • Requires prior authorization

      • MAT for opioid addiction when using drugs other than methadone

        • Billing code: 1-H2010

        • Requires prior authorization

    • MAT for treatment of non-opioid addiction

      • Billing code: 1-H2010

      • Requires prior authorization


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Substance Use Benefits Available January 1, 2011

  • Residential treatment

    • Billing code: 1-H0011

    • Requires prior authorization

  • Residential detoxification

    • Billing code: 1-H0047, 1-H2036 (per diem)

    • Requires prior authorization



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Pre-Certification Form

  • For initial requests, please provide a brief narrative of the member’s clinical presentation

    • This information should be entered under “Evaluation of initial treatment”

  • For continuation requests, please include a summary of why services need to continue

    • This information should be included under “For continuation of therapy requests . . .”




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Pre-Authorization: FAQ’s

  • What is the difference between date of admission and date of procedure?

  • Admission date – The date a member is admitted to an inpatient facility

  • Date of procedure – The date the provider is going to conduct the requested CPT Code (i.e. 90806, 90847)

  • Do I fill out CPT Codes or Revenue Codes (Rev Codes)?

  • CPT Codes are common for most outpatient providers

  • Revenue Codes are used by facility providers

  • (i.e. psychiatric hospitals)


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Texas Health and Human Services Commission

HHSC Reference:

http://www.hhsc.state.tx.us/SubstanceAbuseBenefit.shtml#Announcements


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Behavioral Health Case Management

  • Team of nurses and social workers assist with the following:

    • Access and coordinate services

    • Integrate care for individuals with a dual diagnosis

    • Provide referrals to community resources for basic needs

    • Referrals are accepted by the Case Management Coordinator at (915) 532-3778 or 1-877-532-3778 extension 1090


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El Paso First Crisis Line

  • El Paso First members have access to crisis intervention services 24 hours a day, 7 days a week

    • El Paso First Premier members may call

      1-877-377-6147

    • El Paso First CHIP members may call

      1-877-377-6184


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Questions

Janel Lujan, LMSW

Case Management Coordinator

(915) 532-3778

Extension: 1090


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Claims Department

Claim Submission


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Verification of Authorization

Claims Submission

  • Remember to Bill with valid Diagnosis Codes

  • BOX 21

  • Remember to Point your Diagnosis code to the appropriate Service BOX 24E

  • Submit Your Claim:

    • Hand Written and Typed to

    • El Paso First Health Plans - ClaimsP.O. Box 971370El Paso, TX 79997-1370

    • El Paso First Web Portal at

    • www.epfirst.com

    • Electronic Billing via Clearinghouse

      • To access the EDI Form please go to our website at http://www.epfirst.com/forms/EDIPacket.pdf


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THIN Payer ID # P:\EDI Enrollment (Electronic Claims Submission)\THIN EPFirst EDI


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Submission Process

STEP (1) How can a provider submit claims electronically?

  • The provider may log into the El Paso First Web Portal accessible through the El Paso First Website

  • The provider may submit batch claims through a clearinghouse

    STEP (2) What happens when the claims are received at the clearinghouse?

  • When claims arrive to the designated clearinghouse the claims will be scrubbed by the clearinghouse for HIPPA edits. Any claims that do not pass HIPPA edits will be rejected by the clearinghouse up front and the plan will never received the claims.

  • The clearinghouse will send a response back to the provider with any claim rejections and error message. The provider will need to correct the claims and resubmit.

  • All claims that pass the clearinghouse HIPPA edits will then be transferred to the carrier (El Paso First Health Plans).


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Submission Process

STEP (3, 4, 5) What happens when the claims are received at the carrier (El Paso First Health Plans)?

  • El Paso First imports all batch files received from the clearinghouse daily.

  • The El Paso First import system will run the claims through system edits.

  • Any claims that do not pass the El Paso First system edits will be rejected and returned back with a response report (997 text file) back to the clearinghouse.

  • The clearinghouse will then transmit the information back to the provider for corrections. The provider will need to correct the claim and resubmit.

  • All claims that pass the system edits will import into the core claims processing system.


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Submission Process

STEP (6, 7, 8)What happens when the claims are imported to the El Paso First claims processing system?

  • All imported claims will run through auto adjudication on a nightly basis.

  • 80 percent of the claims will auto adjudicate and pay/deny

  • 20 percent of the claims will adjudicate and Pend for manual review




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To Check Claim Status

  • Providers may utilize the following resources:

    • Web portal account (www.epfirst.com)

    • HealthX Fax System at 915-225-5463 (24 hours a day 7 days a week)

    • Call the Provider Care Unit at 915-532-3778 extension 1504


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Claim/Appeal Filing Deadlines

  • Claims must be received by El Paso First within 95 days from DOS

  • Corrected claims must be re-submitted within 120 days from the R.A. (Remittance Advice)

  • When a service is billed to another insurance resource, the filing deadline is 95 days from the date of the disposition by the other insurance carrier.

  • It is strongly recommended providers who submit paper claims keep a copy of the documentation they send. It is also recommended paper claims be sent by certified mail with return receipt requested & a detailed listing of the claims enclosed.

    .


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Provider Care Unit and how it works

Contact us at 915-532-3778

When calling you will reach a Claims specialist who will:

  • Give claim status calls.

  • Resolve or answer claim questions.

  • Answer Electronic claims submission rejections or questions.

  • Assist with claims disputes.

  • Corrected Claims


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Complaints and Appeals

  • Complaint Process :

  • Acknowledgement

  • Resolution

  • What is a level 1 Appeal

  • What is a level 2 Appeal

  • Please note you have the right to appeal any disposition of a claim through a formal appeal. Written request must be mailed to:

  • El Paso First Health Plans, Inc

  • Attn: Complaints and Appeals Department

  • POBOX 971100, El Paso, Texas 79997-1370

  • Within 120 days from the date of your Provider Remittance Advice.


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Questions?

Thank you for your attendance!


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