Presentation on theme: "WELCOME PROVIDERS Thursday, February 25, 2010. El Paso First Health Plans, Inc. Chief Executive Officer Carol Smallwood."— Presentation transcript:
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
Provider Relations - SURVEY
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Getting Ready for ICD - 10 WHAT: Preparing for the conversion from ICD9 to ICD 10 ICD 9 – outdated over 30 years old, technological changes, not descriptive enough WHY: Provide a better specificity on clinical information Improve quality of care Enhances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 For ICD 10 – PCS
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 (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, 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 Health Svcc Admin Supervisor Ji Jim Voiland, MBA, MSN, RN, LP Director of Health Services Manager of System Data Melinda Verosky Director of Finance Melly Pracht Manager of Human Resources Rocio Chavez Director of Compliance Sharon Perkins Manager of Information Technology Sonia Lopez Director 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)
CommitteeResponsibilities Meeting 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 occur 6.Centralizing and coordinating the integration of all quality improvement activities 7.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 Recredentialing 2.Corrective Action Plans, Medical Record Reviews 3.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 process 4.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
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. The purpose of conducting these surveys is to ensure that our members have 24-hour availability and appointment accessibility to their health care provider.
Member Services Department Edgar Martinez – Director of Member Services
Member Service Helpline (915) or Medicaid/STAR ext CHIP ext Preferred Administrators ext Health Care Options (HCO) ext 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: 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
ASQ and PEDS Screening Tools These screening tools will become mandatory in 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
Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Change
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 Childrens Services – Sensory Screening – Laboratory Services – Acute & Chronic Mental Conditions – Pharmacy For more information please go to
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.training 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 with U5 modifier. Must be billed with one of the following medical checkup codes: – – – – 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:
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.
Contact Information If you have any questions or concerns please contact me at: – – Phone: (915) 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.
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