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
Telephone: (915) 532-3778, Fax: (915)532-2877
IMPORTANT: Completion of this form is not considered a binding contract with El Paso First. For more information
on contract plans for participation please contact your Provider Relations Representative.
Demographic Information Form
Please Check off Health Plan Participation (Contract):
Medicaid/Premier Plan
HCO
CHIP
TPA (Preferred Admin)
CHIP Perinate
Group/Facility Name
Group NPI:
Group TPI:
Provider Name (Last, First, Middle):
Individual NPI:
Primary Specialty:
Medical License:
Please check off Specialty Type:
PCP
Allied Health (PT,OT, ST, LPC)
Specialist
Ancillary (DME, Home Health, Facility)
Group Tax-ID:
Professional Category:
MD
DO
CRNA
NP
Other :
Individual TPI:
Pending (in process)
PA
LPC
Received and Attested
Sub-Specialty:
If applicable EPSDT Number :
Provider Billing Information
W-9 must be submitted along with Demographic Information Form
Official Business Name (as it appears on W-9/IRS Documentation)
Doing Business As (if different from above) **this information must match Box #33 on claim form
Billing Address, City State and Zip Code:
Tax ID Number:
Information will be listed in Provider Directories
Primary Practice Location
Secondary Practice Location
Address:
Address:
City, Zip Code:
City, Zip Code:
Phone Number:
Fax:
Phone Number:
Fax Number:
(
)
(
)
(
)
(
)
Languages Spoken: English
Spanish
Accepting New Patients
Other
Established Patients Only
Practice Limitations: Male Only
Female Only
Age Range (
)
Other
Office Days/Hours:
Office Days/Hours:
After Hours:
After Hours:
CLIA:
Waiver
Certificate
CLIA:
Waiver
Certificate
Laboratory:
Yes
No
Laboratory:
Yes
No
Please list a primary office contact for questions surrounding information provided on this form.
Primary Contact Person First and Last Name:
Phone Number:
email address:
(
)
For EP First Provider Relations Staff Only: PR Rep Name:
Contract Request Date:
/
/ ____
Verifications:
W-9
NPPES
TPI Look Up
Other
Credentialed:
YES
NO (IN PROCESS)
Date Application Submitted to Credentialing: _____/______/___________
Contract Type:
Individual
Group
Attachment D
Ancillary
Facility
LOA
Plans:
STAR
CHIP
CHIP Perinate
HCO
CM
TPA
_
Contract Received Date: __
/______/___ ____
Configuration:
System Data Analyst Name:___________________________________________Date Entered in QNXT:_________/_______/________
Claims:
Claims Rep Name:____________________________________________________Date Submitted to Config:____ /_______/________
Special Notes:
Provider Relations - SURVEY
Provider/Group Name:__________________________________
Provider Type:
PCP
Specialist
Ancillary
P
Orientation Evaluation Form February 25, 2010
Please indicate your level of satisfaction with today’s session by circling the appropriate number rating:
4
Excellent
3
Good
2
Average
1
Poor
4
3
2
1
Level of satisfaction with the topics discussed in today’s session.
4
3
2
1
What is your evaluation of today’s speaker(s)?
4
3
2
1
Overall satisfaction with El Paso First Health Plans.
4
3
2
1
El Paso First’s referral and authorization process.
4
3
2
1
El Paso First’s accuracy and timeliness of claims payment.
El Paso First’s process of verifying and providing member
information.
El Paso First’s Provider Relations/Contracting Department.
4
3
2
1
4
3
2
1
4
3
2
1
THSteps level of satisfaction (EPSDT providers only).
4
3
2
1
Overall satisfaction with today’s presentation.
Please check off the type of information/training you would like to receive:
Claims:
Other:
Understanding RA’s
Proof Timely Filing
Rejection Types
PCP Assignment
Program Benefits
Eligibility
Update Information/
New Enrollments
Understanding your
Contracts
Pre Authorizations
Case Management
Account Set-Up
Capability
PCU
Member Services:
Other:
Provider Relations:
Other:
Health Services:
Other
Quality
Improvement
Web Portal:
Formal Appeals
Medical Chart Audits
Compliance:
STAR/Premier
EPF Programs:
THSteps:
CHIP/CHIP Perinate
HCO
Periodicity Schedule
Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
TPA
PCP ROSTERS (New Feature)
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
Health Services Department
Jim Voiland – Director of Health Services
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
Quality Improvement Committee
and Sub-Committees
QUALITY
IMPROVEMENT
COMMITTEE
(QIC)
PHYSICIAN
ADVISORY
CREDENTIALING
AND
UTILIZATION
OPERATIONS
MANAGEMENT
IMPROVEMENT
COMMITTEE
PEER REVIEW
COMMITTEE
COMMITTEE
(PAC)
COMMITTEE
(UMC)
(OIC)
(CPRC)
Quality Improvement Committee
(QIC)
Physician Advisory Committee
(PAC)
Credentialing and Peer Review
Committee (CPRC)
Utilization Management
Committee (UMC)
Da
Operations Improvement
Committee (OIC)
David M. Palafox, M.D.
(Chairman)
(Medical Director)
Mark Lawson, M.D. (Chairman)
(Pediatrician)
M. Palafox, M.D.
(Chairman)
Carol Smallwood (Chairman)
CEO/President
C
Cenan Antowan, M.D.
(Pediatrician)
David Palafox, M.D.
(Medical Director)
Stefan Sarre, M.D.
(Associate Medical Director)
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
Jacob Heydemann, M.D.
(Ortho)
Christine Hernandez, M.D.
(Family Practitioner)
Fernando Raudales, M.D.
(Nephrologist)
*
Frank Dominguez
Director of Provider
Relations/Contracting
Robert Santoscoy, M.D.
(Pediatric and Adult
Cardiovascular Surgery)
Michael Schaffer, M.D.
(OB/GYN)
Jim Voiland, RN
(Director of Health Services)
Gary Schabacker, M.D.
(Surgery)
*Jim Voiland, RN
(Director of Health Services)
*Colleen Grady, RN
(Manager of Quality Improvement)
Wayne O. Ghans, M.D.
(Family Practitioner)
*Colleen Grady, RN
(Manager of Quality Improvement)
Manager of System Data
*Jim Voiland, RN
(Director of Health Services)
*Irma Vasquez
(Health Services Administrative
Supervisor)
Melinda Verosky
Director of Finance
*Colleen Grady, RN
(Manager of Quality Improvement)
Irma Vasquez
Health Svcc Admin
Supervisor
Ji
Jim Voiland, MBA, MSN, RN, LP
Director of Health Services
Melly Pracht
Manager of Human Resources
Rocio Chavez
Director of Compliance
Sharon Perkins
Manager of Information
Technology
Sonia Lopez
Director of Claims
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)
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)
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)
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)
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)
Committee
Responsibilities
6.
7.
8.
Oversee, Support and Implement the Quality Improvement Program and Annual work plan.
Implementing corporate policy related to quality and organizations quality improvement programs.
Objective measures used to gauge the quality of care and services provided.
Assuring activities of QI are in place and working effectively to monitor and improve quality.
Assuring that quality improvement efforts are prioritized, resources are appropriate, and system-wide trends are
identified and analyzed, and that follow-up and resolution occur
Centralizing and coordinating the integration of all quality improvement activities
Adopting national and local practice guidelines and clinical standards of care and policies of medical practice.
Analyzing and evaluating summary data.
Credentialing and
Peer Review
Committee (CPRC)
1.
2.
3.
4.
Credentialing and Recredentialing
Corrective Action Plans, Medical Record Reviews
Approving office site visit forms and procedures.
Resolution of Clinical issues that affect members’ health status.
Utilization
Management
Committee (UMC)
1.
2.
3.
4.
5.
6.
Establish guidelines for utilization management.
Monitor, Evaluate and make determinations regarding timely, effective, and appropriate level of utilization services.
Review and Approve medical criteria in the utilization process
Reviewing summary statistics, including over-and-under utilization.
Recommending and Reviewing clinical practice guidelines.
Oversight of delegated utilization activities.
Quarterly
1.
Reviewing the health service processes and giving feedback to health professionals and staff regarding performance and
patient results.
Recommending action plans and evaluating the effectiveness of the results.
Reviewing and approving recommended guidelines.
Reviewing over and under utilization data.
Assisting in the development of a provider profiling system.
As needed
Implements the Quality Improvement Program and Annual Work Plan.
Utilizes the quality improvement approach by using continual efforts to make the organization more efficient and meet
quality improvement goals.
Quarterly
Quality
Improvement
Committee (QIC)
1.
2.
3.
4.
5.
Meeting
Times
Physician Advisory
Committee (PAC)
2.
3.
4.
5.
Operations
Improvement
Committee (OIC)
1.
2.
Quarterly
Monthly
The purpose of conducting these surveys is to ensure that
our members have 24-hour availability and appointment
accessibility to their health care provider.
We will select a random sampling of the provider pool every quarter.
The Provider will:
1) Receive one request to answer a page after hours (week nights and
weekends).
2) Receive a call during the daytime to check appointment accessibility
standards.
Specialty
Family Practice
24-hour Availability
1st
Qtr
2nd Qtr
10
13
3rd Qtr
4th Qtr
0
12
7
10
7
7
8
GYN
OB-GYN
9
10
7
9
INTERNAL MEDICINE
Pediatrics
10
8
11
10
0
5
1
0
Psychology
0
1
1
0
24-hour
Total
Physicians
Surveyed
Met
Met
93
108
25
20
22
8
OB-GYN
13
PEDIATRICS
13
PSYCHIATRY
NON COMPLIANT
21
COMPLIANT
24
5
1
2
PSYCHOLOGY
Office Accessibility
Not Met
0
GYN
55
20
1
10
40
10
*A total of 168 providers were contacted , 12% have moved out of
town or are no longer at location contacted.
PSYCHOLOGY
40
28
NON COMPLIANT
20
3
31
12
PEDIATRICS
PSYCHIATRY
30
1
INTERNAL MEDICINE
OB-GYN
20
10
FAMILY PRACTICE
148
15
18
Office
Not met
10
FAMILY PRACTICE
Internal Medicine
Psychiatry
5
3
3
2
25
COMPLIANT
1st
Qtr
Specialty
Family Practice
10
Internal
Medicine
10
OB-GYN
10*
Pediatrics
10
Total
Physicians
Surveyed
39
2nd
Qtr
3rd
Qtr
24-hour
4th
Qtr
Office
Met Not met Met Not Met
22
17
*An OB/GYN Provider was contacted and
is no longer in practice
31
8
Member Services Department
Edgar Martinez – Director of Member Services
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
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
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
THSteps Updates
By Michelle Anguiano
Provider Relations
THSteps Coordinator
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=b48ca997-4760-4d81-9401-5f92a493dd5d
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.
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/
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.
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
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.
Contact Information
• If you have any questions or concerns please
contact me at:
– E-mail: manguiano@epfirst.com
– Phone: (915)298-7198 extension 1053.
Claims Department
Sonia Lopez – Director of Claims
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.
.
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.
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
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.
Questions?
Please don’t forget to fill out our survey.
Thank you for your participation
and have a great day!