WELCOME PROVIDERS

Thursday , February 25, 2010

El Paso First Health Plans, Inc.

Chief Executive OfficerCarol 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

Please check off Specialty Type: PCP Allied Health (PT,OT, ST, LPC) Specialist Ancillary (DME, Home Health, Facility)

Group/Facility Name Group NPI: Group TPI:

Group Tax-ID:

Provider Name (Last, First, Middle):

Professional Category: MD DO CRNA NP PA LPC Other :

Individual NPI: Individual TPI: Pending (in process) Received and Attested Primary Specialty: Sub-Specialty: Medical License: 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 Other

Accepting New Patients Established Patients Only

Practice Limitations: Male Only Female Only Age Range ( ) Other Office Days/Hours: After Hours:

Office Days/Hours: After Hours:

CLIA: Waiver Certificate Laboratory: Yes No

CLIA: Waiver Certificate 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 P Provider/Group Name:__________________________________ Provider Type: PCP Specialist Ancillary

Orientation Evaluation Form February 25, 2010

Please indicate your level of satisfaction with today’s session by circling the appropriate number rating: 4 3 2 1

Excellent Good Average Poor

Overall satisfaction with today’s presentation. 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. 4 3 2 1

El Paso First’s process of verifying and providing member information.

4 3 2 1

El Paso First’s Provider Relations/Contracting Department. 4 3 2 1

THSteps level of satisfaction (EPSDT providers only). 4 3 2 1

Please check off the type of information/training you would like to receive:

Claims: Other:

Understanding RA’s Proof Timely Filing Rejection Types PCU

Member Services: Other:

PCP Assignment Program Benefits Eligibility

Provider Relations: Other:

Update Information/ New Enrollments

Understanding your Contracts

Health Services: Other

Pre Authorizations Case Management Quality Improvement

Web Portal:

Account Set-Up Capability

Compliance:

Formal Appeals Medical Chart Audits

EPF Programs:

STAR/Premier CHIP/CHIP Perinate HCO TPA

THSteps: Periodicity Schedule

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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 athttp://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 DepartmentJim 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 IMPROVEMEN

T

COMMITTEE

(QIC)

PHYSICIAN ADVISORY

COMMITTEE

(PAC)

CREDENTIALING AND

PEER REVIEW

COMMITTEE

(CPRC)

UTILIZATION

MANAGEMENT

COMMITTEE

(UMC)

OPERATIONS

IMPROVEMENT

COMMITTEE

(OIC)

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)

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)

Mark Lawson, M.D. (Chairman)

(Pediatrician)

David 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)

Da

M. Palafox, M.D. (Chairman)

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)

Carol Smallwood (Chairman)

CEO/President C

Colleen Grady, RNManager of Quality

Improvement

David Palafox, M.D.Medical Director

Edgar MartinezDirector of Member Services

Frank DominguezDirector of Provider

Relations/Contracting

Irma VasquezHealth Svcc Admin

SupervisorJi

Jim Voiland, MBA, MSN, RN, LPDirector of Health Services

Manager of System Data

Melinda VeroskyDirector of Finance

Melly PrachtManager of Human Resources

Rocio ChavezDirector of Compliance

Sharon PerkinsManager of Information

Technology

Sonia LopezDirector of Claims

*Colleen Grady, RN(Manager of Quality

Improvement)

*Irma Vasquez(Health Services

Administrative Supervisor)

Quality Improvement Committee (QIC)

David M. Palafox, M.D. (Chairman)Medical Director

Jose Aun, M.D.(OB/GYN)

Andres Enriquez, M.D.(Family Practitioner)

C. Antonio Jesurun, M.D.(Neonatologist)

*Elizabeth Nuevo(Health Plan Member)

*Jim Voiland, RN(Director of Health Services)

*Colleen Grady, RN(Manager of Quality Improvement)

Rodolfo Leyva, M.D.(Pediatrician)

Martin Guerrero Jr., M.D., J.D.(Psychiatry)

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 ResponsibilitiesMeeting Times

Quality Improvement

Committee (QIC)

1. Oversee, Support and Implement the Quality Improvement Program and Annual work plan.2. Implementing corporate policy related to quality and organizations quality improvement programs.3. Objective measures used to gauge the quality of care and services provided.4. Assuring activities of QI are in place and working effectively to monitor and improve quality.5. Assuring that quality improvement efforts are prioritized, resources are appropriate, and system-wide

trends are identified and analyzed, and that follow-up and resolution occur6. Centralizing and coordinating the integration of all quality improvement activities7. Adopting national and local practice guidelines and clinical standards of care and policies of medical

practice.8. Analyzing and evaluating summary data.

Quarterly

Credentialing and Peer Review

Committee (CPRC)

1. Credentialing and Recredentialing2. Corrective Action Plans, Medical Record Reviews3. Approving office site visit forms and procedures.4. Resolution of Clinical issues that affect members’ health status.

Monthly

Utilization Management Committee

(UMC)

1. Establish guidelines for utilization management.2. Monitor, Evaluate and make determinations regarding timely, effective, and appropriate level of utilization

services.3. Review and Approve medical criteria in the utilization process4. Reviewing summary statistics, including over-and-under utilization.5. Recommending and Reviewing clinical practice guidelines.6. Oversight of delegated utilization activities.

Quarterly

Physician Advisory

Committee (PAC)

1. Reviewing the health service processes and giving feedback to health professionals and staff regarding performance and patient results.

2. Recommending action plans and evaluating the effectiveness of the results.3. Reviewing and approving recommended guidelines.4. Reviewing over and under utilization data.5. Assisting in the development of a provider profiling system.

As needed

Operations Improvement

Committee (OIC)

1. Implements the Quality Improvement Program and Annual Work Plan.2. Utilizes the quality improvement approach by using continual efforts to make the organization more

efficient and meet quality improvement goals.Quarterly

Member Services Department Edgar Martinez – Director of Member Services

Member Service Helpline(915)-532-3778 or 1-877-532-3778 (915)-532-3778 or 1-877-532-3778

Medicaid/STAR ext. 1514CHIP ext. 1517Preferred Administrators ext.

1529Health Care Options (HCO) ext.

1502

Office Business Hours: Monday- Friday 8:00 AM – 5:00 PMHours of Call Center Operation: 7:00 AM – 6:00 PMAfter 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 AnguianoProvider 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!