Transcript Slide 1

El Paso First
Quarterly Provider Meeting
Wednesday November 11, 2009
El Paso First Team
Frank Dominguez – Director, Provider Relations and Contracting
Irma Herrera – Supervisor, Provider Relations
Cynthia Moreno – Provider Relations Representative
Rene Duran – Provider Relations Representative
Michelle Anguiano – Provider Relations THSteps Coordinator
Eva Ortiz – Provider Relations Representative
Evelyn Lopez– Contracting Representative
Cindy Avalos – Contracting Representative
Jim Voiland – Health Services Director
Edgar Martinez– Member Services Director
Lluvia Acuna – Migrant Outreach Coordinator
Sonia Lopez – Claims Director
Corina Diaz – Complaint and Appeals Specialist
EL Paso First Health Plans, Inc.
WE ARE MOVING! – DECEMBER 18, 2009!
Our new address is:
1145 Westmoreland Drive
El Paso, TX 79925-5615
Please note:
Paper Claim submissions will continue to go to:
El Paso First Health Plans - Claims
P.O. Box 971370
El Paso, X 79997-1370
Our General Correspondence address will not change.
P.O. Box 971100
El Paso, TX 79997-1100
NEW LOCATION
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!
Health Services Department
Jim Voiland
Health 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.
Reminder – medium and high risk newborns – phototherapy is not a
covered benefit for home use.
Providers MUST submit documentation to support medical necessity
(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.
THSteps Updates
Michelle Anguiano
THSteps Coordinator
Provider Relations Department
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 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
Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Change
http://www.tmhp.com/txtlstvw.aspx?LstID=b48ca997-4760-4d81-94015f92a493dd5d
Mental Health Screening Tools
Should 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 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 Martinez
Member Services Director
El
Paso
First
Premier
Plan
(Medicaid)
Texas Health Steps Exams
•$15
packet
with OTC
How
doWelcome
you know when
a member
is due for a THSteps exam:
medications.
•Preventive
Services
for pregnant
Their
3087 willDental
state that
they are due
members over 21 years of age.
•Eyeglasses
valued
to $125
Member’s
due are
listed up
on your
Provider Roster
•Free Transportation for medical
appointments.
Call
El Paso First to verify if the member is due for a
•Additional
counseling
services
THSteps examnutritional
at (915) 532-3778
or 1-877-532-3778
for members under 21 years of age.
•Additional Behavioral Health services.
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.
Page 1
El Paso First CHIP Perinatal Plan (CHIP Perinatal)
•$15 Welcome packet with OTC
medications.
•Free Transportation for medical
appointments.
Page 1
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.
Do you assist any Seasonal Farm
Workers?
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.
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
Questionnaire/ Cuestionario
Dear member, let us help you:
Estimado miembro, permítanos ayudarle:
El Paso First Premier Plan has special Medicaid
services 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 Coordinator
at (915) 532-3778. We will help you receive
accelerated services. Thank you for your time!
El Plan Premier de El Paso First tiene servicios
especiales de Medicaid para niños de trabajadores
temporales del campo, por eso nos gustaría saber
lo 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, por
favor comuniquese con Lluvia Acuña, Coordinadora
Migrante, al (915) 532-3778. Le ayudaremos a
recibir servicios rápidos. ¡Gracias por su tiempo!
Contact Information
Lluvia Acuña
Migrant Outreach Coordinator
(915) 532-3778 ext. 1075
Laura Caldelas
Outreach Supervisor
(915) 532-3778 ext. 1108
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 Director
Corina 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?
Acknowledgement
Resolution
What is a level 1 Appeal?
What is a level 2 Appeal?
Corrected Claims?
Claims Department
Sonia Lopez
Claims 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!