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WELCOME PROVIDERS

WELCOME PROVIDERS. Thursday , February 25, 2010. El Paso First Health Plans, Inc. Chief Executive Officer Carol Smallwood. Provider Relations Department Updates. Electronic Fund Transfers/ New Demographic Form. Provider Relations - SURVEY. PCP ROSTERS (New Feature).

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WELCOME PROVIDERS

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  1. WELCOME PROVIDERS Thursday , February 25, 2010

  2. El Paso First Health Plans, Inc. Chief Executive Officer Carol Smallwood

  3. Provider Relations Department Updates

  4. Electronic Fund Transfers/ New Demographic Form

  5. Provider Relations - SURVEY

  6. PCP ROSTERS (New Feature)

  7. Getting Ready for ICD - 10 • WHAT: Preparing for the conversion from ICD9 to ICD 10 • ICD 9 – outdated over 30 years old, technological changes, not descriptive enough • WHY: Provide a better specificity on clinical information • Improve quality of care • Enhances ability for better public health reporting • Decrease need to include supporting documentation with claims • Reimbursement – would enhance accurate payment for services rendered • WHEN: Replacement compliance date October 2013 • For more information on ICD 10 – CM can be found at • http://www.cdc.gov/nchs/icd/icd10cm.htm • For ICD 10 – PCS http://www.cms.hhs.gov/icd10/01_overview.asp#top%20pf%20page

  8. Health Services Department Jim Voiland – Director of Health Services

  9. Health Services Department • Care Management Resources • Extensive Case Management Resources • Complex cases • OB • Asthma • Diabetes • CSHCN • Disease Management • OB Ultrasounds preauthorization modifications • Behavioral Health Outpatient preauthorization • Specialized provider orientation OB/BH

  10. QUALITY IMPROVEMENT COMMITTEE (QIC) PHYSICIAN ADVISORY COMMITTEE (PAC) CREDENTIALING AND PEER REVIEW COMMITTEE (CPRC) UTILIZATION MANAGEMENT COMMITTEE (UMC) OPERATIONS IMPROVEMENT COMMITTEE (OIC) Quality Improvement Committee and Sub-Committees

  11. Quality Improvement Committee (QIC) Physician Advisory Committee (PAC) Credentialing and Peer Review Committee (CPRC) Utilization Management Committee (UMC) Operations Improvement Committee (OIC) David M. Palafox, M.D. (Chairman) (Medical Director) Mark Lawson, M.D. (Chairman) (Pediatrician) Da M. Palafox, M.D. (Chairman) Carol Smallwood (Chairman) CEO/President Cenan Antowan, M.D. (Pediatrician) David Palafox, M.D. (Medical Director) Stefan Sarre, M.D. (Associate Medical Director) C Colleen Grady, RN Manager of Quality Improvement Javier Corral, M.D. (Internal Medicine) Jose Aun, M.D. (OB/GYN) Mark Lawson, M.D. (Pediatrician) David Palafox, M.D. Medical Director Mitchell Farrell, M.D. (Family Practitioner) Tony Martinez, M.D. (Family Practitioner) Frederick Harlass, M.D. (OB/GYN) Edgar Martinez Director of Member Services Frank Dominguez Director of ProviderRelations/Contracting Jacob Heydemann, M.D. (Ortho) Christine Hernandez, M.D. (Family Practitioner) Fernando Raudales, M.D. (Nephrologist) Robert Santoscoy, M.D. (Pediatric and AdultCardiovascular Surgery) Michael Schaffer, M.D. (OB/GYN) * Jim Voiland, RN (Director of Health Services) Irma Vasquez Health Svcc Admin Supervisor Gary Schabacker, M.D. (Surgery) *Jim Voiland, RN (Director of Health Services) *Colleen Grady, RN (Manager of Quality Improvement) Ji Jim Voiland, MBA, MSN, RN, LP Director of Health Services Wayne O. Ghans, M.D. (Family Practitioner) *Colleen Grady, RN (Manager of QualityImprovement) Manager of System Data *Jim Voiland, RN (Director of Health Services) *Irma Vasquez (Health Services AdministrativeSupervisor) Melinda Verosky Director of Finance *Colleen Grady, RN (Manager of QualityImprovement) Melly Pracht Manager of Human Resources Rocio Chavez Director of Compliance Sharon Perkins Manager of Information Technology Sonia Lopez Director of Claims

  12. Quality Improvement Committee (QIC) David M. Palafox, M.D. (Chairman) Medical Director Jose Aun, M.D. (OB/GYN) Martin Guerrero Jr., M.D., J.D. (Psychiatry) Andres Enriquez, M.D. (Family Practitioner) C. Antonio Jesurun, M.D. (Neonatologist) Rodolfo Leyva, M.D. (Pediatrician) *Elizabeth Nuevo (Health Plan Member) *Jim Voiland, RN (Director of Health Services) *Colleen Grady, RN (Manager of Quality Improvement)

  13. Physician Advisory Committee (PAC) David M. Palafox, M.D. (Chairman) Medical Director Cenan Antowan, M.D. (Pediatrician) Javier Corral, M.D. (Internal Medicine) Mitchell Farrell, M.D. (Family Practitioner) Jacob Heydemann, M.D. (Ortho) Robert Santoscoy, M.D. (Pediatric and Adult Cardiovascular Surgery) Gary Schabacker, M.D. (Surgery) Wayne O. Ghans, M.D. (Family Practitioner) *Jim Voiland, RN (Director of Health Services) *Colleen Grady, RN (Manager of Quality Improvement)

  14. Credentialing and Peer Review Committee (CPRC) Mark Lawson, M.D. (Chairman) (Pediatrician) David M. Palafox, M.D. Medical Director Jose Aun, M.D. (OB/GYN) Tony Martinez, M.D. (Family Practitioner) Christine Hernandez, M.D. (Family Practitioner) Michael Schaffer, M.D. (OB/GYN) *Jim Voiland RN (Director of Health Services) *Colleen Grady, RN (Manager of Quality Improvement) *Irma Vasquez (Health Services Administrative Supervisor)

  15. Utilization Management Committee (UMC) David M. Palafox, M.D. (Chairman) (Medical Director) Stefan Sarre, M.D. Associate Medical Director Mark Lawson, M.D. (Pediatrician) Frederick Harlass, M.D. (OB/GYN) Fernando Raudales, M.D. (Nephrologist) *Jim Voiland RN (Director of Health Services) *Colleen Grady, RN (Manager of Quality Improvement)

  16. Operations Improvement Committee (OIC) Carol Smallwood - Chair (CEO/President) Colleen Grady, RN (Manager of Quality Improvement) David Palafox, M.D. (Medical Director) Edgar Martinez (Director of Member Services) Frank Dominguez (Director of Provider Relations/Contracting) Irma Vasquez (Supervisor of Health Services Administrative) Jim Voiland, MBA, MSN, RN, LP (Director of Health Services) (Manager of System Data Analyst) Melinda Verosky (Director of Finance) Melly Pracht (Manager of Humana Resources) Rocio Chavez (Director of Compliance) Sharon Perkins (Manager of Information Technology) Sonia Lopez (Director of Claims)

  17. 24 hour Availability & Office Accessibility Surveys

  18. Surveys

  19. SFY 2009 Results

  20. SFY 2010 1st Quarter Results

  21. Member Services Department Edgar Martinez – Director of Member Services

  22. Member Service Helpline (915)-532-3778 or 1-877-532-3778 Medicaid/STAR ext. 1514 CHIP ext. 1517 Preferred Administrators ext. 1529 Health Care Options (HCO) ext. 1502 Office Business Hours: Monday- Friday 8:00 AM – 5:00 PM Hours of Call Center Operation: 7:00 AM – 6:00 PM After Hour Service: 24 hours a day 7 days a week

  23. Member Services Department Contacts Edgar Martinez- Member Services Director Monica Esparza- Member Services & Enrollment Supervisor Antonio Medina- Enrollment & Member Services Supervisor Beatriz Esparza- Outreach Supervisor Lluvia Acuña- Migrant Outreach Coordinator

  24. Member Services Primary Functions include: • Main phone number: 532-3778 • Verify eligibility for all providers • Explain to members and providers what benefits are covered • Conduct outbound reminder calls to THSteps members • Help find or change Primary Care Providers • Document initial member complaints • Arrange transportation or interpreter services for members • Mail out member ID cards, handbooks and directories • Assists members with CHIP/Medicaid Applications • Inform members about educational classes and health fairs

  25. THSteps Updates By Michelle Anguiano Provider Relations THSteps Coordinator

  26. Periodicity Schedule Effective September 1, 2009

  27. ASQ and PEDS Screening Tools • These 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

  28. Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Changehttp://www.tmhp.com/txtlstvw.aspx?LstID=b48ca997-4760-4d81-9401-5f92a493dd5d

  29. Online Provider Education • 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.  HHSC and DSHS agencies intend to recognize providers on a quarterly basis on the HHSC website.  • Providers can earn FREE continuing education credits to enhance their ability to provide preventive health, mental health, oral health & case management services to Medicaid eligible children in Texas. • The web-based modules provide relevant information and reference materials on more than 24 topics. You can access useful resources on this site at any time on an unlimited basis, even when not taking a course.

  30. Online Provider Education • The courses currently being offered are: • Pediatric Referral Guidelines • Genetic Screening • Case Management • Oral Health • Developmental/Mental Screening • Prevention & Wellness • Adolescent Health • Overview of Best Practices and Children’s Services • Sensory Screening • Laboratory Services • Acute & Chronic Mental Conditions • Pharmacy For more information please go to http://www.txhealthsteps.com/

  31. Oral Evaluation and Fluoride Varnish Trainings Who is eligible to provide this service? • Texas Health Steps enrolled physicians, physician assistants, and advanced practice nurses. Certification • These providers must attend the OEFV training offered by the Department of State Health Services Oral Health Program to become certified to bill for this service. Link to training or scroll to the bottom of this page. • The certification code is placed on the Texas Health Steps TPI under which the provider bills their Texas Health Steps medical checkups. What is included in this visit? • Intermediate oral evaluation. • Fluoride varnish application. • Dental Anticipatory guidance. • Referral to a dental home.**This service must be performed in conjunction with a Texas Health Steps medical checkup.

  32. Oral Evaluation and Fluoride Varnish Trainings How is this service billed to Texas Medicaid? • In conjunction with a Texas Health Steps medical checkup, utilize CPT code 99429 with U5 modifier. • Must be billed with one of the following medical checkup codes:    – 99381    – 99382    – 99391    – 99392 • Reimbursed at $34.16 in addition to the Texas Health Steps checkup reimbursement. • Federally qualified health centers and Rural Health Centers do not receive additional encounter reimbursement. What documentation is needed? • Must document all components of OEFV on the documentation form provided during the training. • Keep record of the referral to a dental home. To register please go to: http://www.dshs.state.tx.us/dental/OEFV_Training.shtm

  33. Accelerated Services for Children of Migrant Farm Workers • State initiative to provide a THSteps checkup and accelerated services to children of migrant farm workers due to the uniqueness of this population. • Collaborating with the Migrant Outreach Coordinator to educate our providers about these services. • If you have any patients from El Paso First that meet this criteria please refer them to Lluvia Acuña, Migrant Outreach Coordinator at 915-532-3778 ext 1075.

  34. Contact Information • If you have any questions or concerns please contact me at: • E-mail: manguiano@epfirst.com • Phone: (915)298-7198 extension 1053.

  35. Claims Department Sonia Lopez – Director of Claims

  36. Claim 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. .

  37. CLAIM PROOF OF TIMELY FILING Note: Office notes indicating claims were submitted on time or personal screen prints of claim submissions are not considered proof of timely filing.

  38. CLAIM PROOF OF TIMELY FILING Submit a copy of an Electronic Claims Report that includes the following information: • Batch submission ID and date • Individual claim that is being appealed • EL Paso First -assigned batch ID number

  39. Top 4 EDI Clearinghouse Rejections • Rendering Provider Taxonomy Code missing or invalid. • National Provider ID (NPI) is required for this payer. • Invalid Diagnosis code • Composite Diagnosis Code Pointer should not be used.

  40. Questions? Please don’t forget to fill out our survey. Thank you for your participation and have a great day!

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