WELCOME PROVIDERS Thursday, February 25, 2010. El Paso First Health Plans, Inc. Chief Executive...
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Transcript of WELCOME PROVIDERS Thursday, February 25, 2010. El Paso First Health Plans, Inc. Chief Executive...
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: [email protected] – 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!