7 Getting Ready for ICD - 10WHAT: Preparing for the conversion from ICD9 to ICD 10ICD 9 – outdated over 30 years old, technological changes, not descriptive enoughWHY: Provide a better specificity on clinical informationImprove quality of careEnhances ability for better public health reportingDecrease need to include supporting documentation with claimsReimbursement – would enhance accurate payment for services renderedWHEN: Replacement compliance date October 2013For more information on ICD 10 – CM can be found atFor ICD 10 – PCS
8 Health Services Department Jim Voiland – Director of Health Services
9 Health Services Department Care Management ResourcesExtensive Case Management ResourcesComplex casesOBAsthmaDiabetesCSHCNDisease ManagementOB Ultrasounds preauthorization modificationsBehavioral Health Outpatient preauthorizationSpecialized provider orientation OB/BH
10 Quality Improvement Committee and Sub-CommitteesQUALITY IMPROVEMENTCOMMITTEE(QIC)PHYSICIAN ADVISORY(PAC)CREDENTIALING ANDPEER REVIEW(CPRC)UTILIZATIONMANAGEMENT(UMC)OPERATIONSIMPROVEMENT(OIC)
11 Health Svcc Admin Supervisor 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.*Jim Voiland, RN(Director of Health Services)*Colleen Grady, RN(Manager of Quality Improvement)Mark Lawson, M.D. (Chairman)David Palafox, M.D.Jose Aun, M.D.(OB/GYN)Tony Martinez, M.D.Christine Hernandez, M.D.Michael Schaffer, M.D.DaM. Palafox, M.D.(Chairman)Stefan Sarre, M.D.(Associate Medical Director)Mark Lawson, M.D.Frederick Harlass, M.D.Fernando Raudales, M.D.(Nephrologist)*Jim Voiland, RNCarol Smallwood (Chairman)CEO/PresidentCColleen Grady, RNManager of Quality ImprovementMedical DirectorEdgar MartinezDirector of Member ServicesFrank DominguezDirector of Provider Relations/ContractingIrma VasquezHealth Svcc Admin SupervisorJiJim Voiland, MBA, MSN, RN, LPDirector of Health ServicesManager of System DataMelinda VeroskyDirector of FinanceMelly PrachtManager of Human ResourcesRocio ChavezDirector of ComplianceSharon PerkinsManager of Information TechnologySonia LopezDirector of Claims*Irma Vasquez(Health Services Administrative Supervisor)
12 Quality Improvement Committee (QIC) David M. Palafox, M.D. (Chairman)Medical DirectorJose 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)
13 Physician Advisory Committee (PAC) David M. Palafox, M.D. (Chairman)Medical DirectorCenan 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.*Jim Voiland, RN(Director of Health Services)*Colleen Grady, RN(Manager of Quality Improvement)
14 Credentialing and Peer Review Committee (CPRC) Mark Lawson, M.D. (Chairman)(Pediatrician)David M. Palafox, M.D.Medical DirectorJose Aun, M.D.(OB/GYN)Tony Martinez, M.D.(Family Practitioner)Christine Hernandez, M.D.Michael Schaffer, M.D.*Jim Voiland RN(Director of Health Services)*Colleen Grady, RN(Manager of Quality Improvement)*Irma Vasquez(Health Services Administrative Supervisor)
15 Utilization Management Committee (UMC) David M. Palafox, M.D. (Chairman)(Medical Director)Stefan Sarre, M.D.Associate Medical DirectorMark 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)
16 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)
17 Committee Meeting Times ResponsibilitiesMeeting TimesQuality Improvement Committee (QIC)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 occurCentralizing and coordinating the integration of all quality improvement activitiesAdopting national and local practice guidelines and clinical standards of care and policies of medical practice.Analyzing and evaluating summary data.QuarterlyCredentialing and Peer Review Committee (CPRC)Credentialing and RecredentialingCorrective Action Plans, Medical Record ReviewsApproving office site visit forms and procedures.Resolution of Clinical issues that affect members’ health status.MonthlyUtilization Management Committee (UMC)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 processReviewing summary statistics, including over-and-under utilization.Recommending and Reviewing clinical practice guidelines.Oversight of delegated utilization activities.Physician Advisory Committee (PAC)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 neededOperations Improvement Committee (OIC)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.
19 We will select a random sampling of the provider pool every quarter. SurveysThe 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.
20 Total Physicians Surveyed SFY 2009 ResultsSpecialty1stQtr2nd Qtr3rd Qtr4th QtrFamily Practice1013127Internal Medicine8OB-GYN9Pediatrics11Psychiatry51PsychologyTotal Physicians Surveyed24-hourOfficeMetNot metNot Met148559310840*A total of 168 providers were contacted , 12% have moved out oftown or are no longer at location contacted.
21 Total Physicians Surveyed SFY st Quarter ResultsSpecialty1stQtr2nd Qtr3rd Qtr4th QtrFamily Practice10Internal MedicineOB-GYN10*PediatricsTotal Physicians Surveyed24-hourOfficeMetNot metNot Met392217318*An OB/GYN Provider was contacted andis no longer in practice
22 Member Services Department Edgar Martinez – Director of Member Services
23 Member Service Helpline (915) orMedicaid/STAR ext. 1514CHIP ext. 1517Preferred Administrators ext. 1529Health Care Options (HCO) ext. 1502Office 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
24 Member Services Department Contacts Edgar Martinez- Member Services DirectorMonica Esparza- Member Services & Enrollment SupervisorAntonio Medina- Enrollment & Member Services SupervisorBeatriz Esparza- Outreach SupervisorLluvia Acuña- Migrant Outreach Coordinator
25 Member Services Primary Functions include: Main phone number:Verify eligibility for all providersExplain to members and providers what benefits are coveredConduct outbound reminder calls to THSteps membersHelp find or change Primary Care ProvidersDocument initial member complaintsArrange transportation or interpreter services for membersMail out member ID cards, handbooks and directoriesAssists members with CHIP/Medicaid ApplicationsInform members about educational classes and health fairs
27 Periodicity Schedule Effective September 1, 2009
28 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
29 Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Change
30 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.
31 Online Provider Education The courses currently being offered are:Pediatric Referral GuidelinesGenetic ScreeningCase ManagementOral HealthDevelopmental/Mental ScreeningPrevention & WellnessAdolescent HealthOverview of Best Practices and Children’s ServicesSensory ScreeningLaboratory ServicesAcute & Chronic Mental ConditionsPharmacyFor more information please go to
32 Oral Evaluation and Fluoride Varnish Trainings Who is eligible to provide this service?Texas Health Steps enrolled physicians, physician assistants, and advanced practice nurses.CertificationThese 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.
33 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 with U5 modifier.Must be billed with one of the following medical checkup codes: – – – – 99392Reimbursed 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:
34 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 ext 1075.
35 Contact InformationIf you have any questions or concerns please contact me at:Phone: (915) extension 1053.
36 Sonia Lopez – Director of Claims Claims DepartmentSonia Lopez – Director of Claims
37 Claim Filing Deadlines Claims must be received by El Paso First within 95 days from DOSCorrected 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..
38 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.
39 CLAIM PROOF OF TIMELY FILING Submit a copy of an Electronic Claims Report that includes the following information:Batch submission ID and dateIndividual claim that is being appealedEL Paso First -assigned batch ID number
42 Top 4 EDI Clearinghouse Rejections Rendering Provider Taxonomy Code missing or invalid.National Provider ID (NPI) is required for this payer.Invalid Diagnosis codeComposite Diagnosis Code Pointer should not be used.
43 Please don’t forget to fill out our survey. Questions?Please don’t forget to fill out our survey.Thank you for your participationand have a great day!
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