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
Agenda
 Provider Relations Overview
 Healthx Fax System
 Substance Abuse Treatment Benefits
 Provider Care Unit (PCU)
 Claim Submission and Appeal Process
 Q/A
Provider Relations Department
Provider Relations Overview
Provider Relations and Contracting Department
 Liaison Between Network Providers, Health Plan and
State Regulators (HHSC and TDI)
 Network Development
(Recruitment)
Call 915-225-5463
 Provider Education
Eligibility Verification
Claims Information
Authorization Information
24 hours a day 7 days a week
STAR/Premier Plan
CHIP and
CHIP Perinate
Health Care Options
Indigent Program
Third Party
Administrator
Commercial Plan
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
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
Call 915-225-5463
• Provider Newsletter
Eligibility Verification
• Provider Forms (Authorization
List, Demographic Update,
Claims Information
Authorization Information
etc.)
• Links
24 hours a day 7 days a week
Waste, Abuse and Fraud Educational Link
TMHP Provider Procedures Manual
CHIP, STAR, and CHIP Perinate Provider Manual
CHIP Health Benefit Plan-Evidence of Coverage
CHIP Perinatal Program for Unborn Children-Evidence of Coverage
Third Party
STAR/Premier Plan
Health Care Options
Administrator
CHIP and
Indigent Program
Commercial Plan
CHIP Perinate
Provider Relations Department Contact Information:
Frank Dominguez
Director of Provider
Relations and Contracting
915-532-3778 ext 1085
fdominguez@epfirst.com
Irma Herrera
Provider Relations
Supervisor
915-532-3778 ext 1018
iherrera@epfirst.com
Evelyn Lopez
Contracting
Representative
915-532-3778 ext 1014
evlopez@epfirst.com
Cindy Avalos
Contracting
Representative
915-532-3778 ext 1068
cavalos@epfirst.com
Cynthia Moreno
Provider Relations
Representative
915-532-3778 ext 1044
cmoreno@epfirst.com
Michelle Anguiano
THSteps Coordinator
915-532-3778 ext 1053
manguiano@epfirst.com
Rene Duran
Provider Relations
Representative
915-532-3778 ext 1037
rduran@epfirst.com
Maritza Lopez
Provider Relations
Representative
915-532-3778 ext 1071
mlopez@epfirst.com
Oscar Gonzalez
Provider Relations
Representative
915-532-3778 ext 1072
ogonzalez@epfirst.com
Questions?
Thank You!!!
Health Services Department
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
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
Pre-Authorization Requirements
 Initial evaluations do not require an
authorization
 Subsequent visits require an authorization
 Behavioral Health Unit will process
authorizations within 72 hours
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
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
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
Pre-Authorization Requirements
PRIOR AUTHORIZATION &
LIMITATIONS
BILLING CODES
No
H0001
Yes
1-H0020
Yes
1-H2010
Yes
1-H2010
Outpatient individual counseling
Yes
26 hours/calendar year
9-H0004
Outpatient group counseling
Yes
135 hours/calendar year
9-H0005
Yes
1-H0014
PRIOR AUTHORIZATION &
LIMITATIONS
BILLING CODES
Yes
1-H0011
Yes
35 days
1-H0047 , 1-H2036 (per diem)
BENEFITS AVAILABLE 09/01/10
Assessment
Medication Assisted Therapy (MAT)*
MAT for opioid addiction with methadone
MAT for opioid addiction with drug other
than methadone
MAT for non-opioid addiction
Outpatient detoxification
BENEFITS AVAILABLE 01/01/11
Residential detoxification
Residential treatment
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 . . .”
Pre-Certification Form
Pre-Certification Form (pg. 2)
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)
Texas Health and Human Services
Commission
HHSC Reference:
http://www.hhsc.state.tx.us/SubstanceAbuseBenefit.shtml#Announcements
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
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
Questions
Janel Lujan, LMSW
Case Management Coordinator
(915) 532-3778
Extension: 1090
Claims Department
Claim Submission
Verification
Authorization
ClaimsofSubmission
•Remember to Bill with valid Diagnosis Codes
BOX 21
Submit Your Claim:
 Hand Written and Typed to
•Remember to Point your Diagnosis code to the appropriate Service
BOX 24E
El Paso First Health Plans - Claims
P.O. Box 971370
El 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
THIN Payer ID #
P:\EDI Enrollment (Electronic Claims Submission)\THIN EPFirst EDI
Payer Name
Payer ID
Medicaid-TX Premier Plan (STAR HMO)
EPF02
El Paso First- CHIP
EPF03
Preferred Administrator
EPF10
Healthcare Options / Care Management
EPF37
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).
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.
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
CMS 1500
CMS 1450 UBO4
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
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.
.
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
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.
Questions?
Thank you for your
attendance!