provider relations and contracting department

5. Provider Relations and Contracting Department Liaison Between Network Providers, Health Plan and State Regulators (HHSC and TDI) Network Development (Recruitment) Provider Education

7. 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

9. Questions?

11. 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

12. 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

13. Pre-Authorization Requirements Initial evaluations do not require an authorization Subsequent visits require an authorization Behavioral Health Unit will process authorizations within 72 hours El Paso First utilizes nationally recognized standards for detoxification and residential treatment admissions. Current guidelines include Milliman Care Guidelines and InterQual. El Paso First utilizes nationally recognized standards for detoxification and residential treatment admissions. Current guidelines include Milliman Care Guidelines and InterQual.

14. 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

15. 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

16. 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

17. Pre-Authorization Requirements * Therapy which uses medication and psychosocial therapy to help consumers to be medication compliant, reduce craving and maintain abstinence. * Therapy which uses medication and psychosocial therapy to help consumers to be medication compliant, reduce craving and maintain abstinence.

18. 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 . . .�

19. Pre-Certification Form

20. Pre-Certification Form (pg. 2)

21. 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)

22. Texas Health and Human Services Commission HHSC Reference: http://www.hhsc.state.tx.us/SubstanceAbuseBenefit.shtml#Announcements

23. 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 Case management is an essential portion of the treatment model as it promotes physical and emotional well being. Case management can be especially helpful when working with mothers who are pregnant and receiving methadone treatment. Case management is an essential portion of the treatment model as it promotes physical and emotional well being. Case management can be especially helpful when working with mothers who are pregnant and receiving methadone treatment.

24. 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

25. Questions Janel Lujan, LMSW Case Management Coordinator (915) 532-3778 Extension: 1090

26. Claims Department

27. Verification of Authorization

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

29. 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).

30. 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.

31. 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

32. CMS 1500

33. CMS 1450 UBO4

34. 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

35. 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. .

36. 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

37. Complaints and Appeals

38. Questions?