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Welcome Please Note: Paper claim submissions will continue to go to: El Paso First Health Plans –Claims P. O. Box 971370 El Paso, Tx 79997-1370 Our general.

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Presentation on theme: "Welcome Please Note: Paper claim submissions will continue to go to: El Paso First Health Plans –Claims P. O. Box 971370 El Paso, Tx 79997-1370 Our general."— Presentation transcript:


2 Welcome

3 Please Note: Paper claim submissions will continue to go to: El Paso First Health Plans –Claims P. O. Box 971370 El Paso, Tx 79997-1370 Our general correspondence address will not change: P.O. Box 971100 El Paso, Tx 79997-1100 1145 Westmoreland Drive El Paso, Tx 79925-5615

4 DepartmentExtensionFax numberDescription Member Services STAR 1514 STAR Sp1518 CHIP 1517 CHIP Sp 1519 HCO 1502 TPA 1529 915-532-2286Eligibility Health Services1500 915-298-7866 (pre-authorizations) Pre-authorizations & Case Management PCUPCU-1504915-298-7867Claims status & Corrections El Paso First Departments Contact Information Main number: 915-532-3778

5 Provider Information In order to have the most updated/ accurate information in our system and in our directories please provide any type of changes to Sun City.

6 El Paso First Health Plans Behavioral Health Unit Health Services Department

7 Pre-Authorization Overview ∙ Pre-Authorization requirements ∙ Pre-Authorization process flow ∙ Pre-Certification Form for Behavioral Health Services ∙ Completion of the Pre-Certification Form -Frequently Asked Questions

8 Pre-Authorization Requirements Initial evaluations do not require an authorization (CPT Code 90801) Subsequent visits for individual and/or family visits require an authorization

9 Pre-Authorization Requirements Pre-Certification form must be faxed to the Behavioral Health Unit at 298-7866 for all inpatient and outpatient requests Behavioral Health Unit will turn around authorizations within 72 hours

10 Pre-Authorization Process Flow Provider faxes El Paso First Pre-certification form is submitted for all inpatient/outpatient requests Fax number: 298-7866 El Paso First begins review process Multi-axial information Current symptoms Response to past treatment Treatment goals CPT Codes, units and frequency Medical director makes determination Final determination based on medical necessity Provider will receive a fax with decision

11 Pre-Authorization Process Flow Providers may call the Behavioral Health Unit directly for questions regarding the status of the authorization request Contact information – 532-3778 x 1500

12 Pre-Certification Form

13 Pre-Certification Form (pg. 2)

14 Completing the Pre-Certification Form Complete the member’s identifying information so an authorization can be generated – Member’s name – Health plan identification number – Date of birth

15 Completing the Pre-Certification Form For initial requests, please provide a brief narrative of the member’s clinical presentation This information should be entered under “Evaluation of initial treatment” For continuation requests, please include a summary of why services need to continue This information should be included under “For continuation of therapy requests...”

16 Pre-Authorization: Frequently Asked Questions What is the difference between date of admission and date of procedure? – Admission date – The date a member is admitted to an inpatient facility – Date of procedure – The date the provider is going to conduct the requested CPT Code (i.e. 90806, 90847) Do I fill out CPT Codes or Revenue Codes (Rev Codes)? – CPT Codes are common for most outpatient providers – Revenue Codes are used by facility providers (i.e. psychiatric hospitals)

17 Pre-Authorization: Frequently Asked Questions How many sessions are authorized? – Medical director will review the number of units requested by the provider and make a decision based on medical necessity How much information is necessary for the pre-certification form? – Brief description that paints a clinical picture of the individual – Updated clinical information is important for continuation requests

18 Modification of Services Denial of Services Modification of Services The Medical Director has approved services with a modification from the original request Example: – Provider requests date of service from 01/29/10 – 11/10/10 – Medical Director approves a date of service from 01/29/10 – 04/29/10 The provider will receive a fax notifying him/her of the modification and an opportunity to discuss the services that were not approved Denial of Services The Medical Director has not approved the requested services Example: – No clinical information is submitted with the pre-certification form – Incorrect ICD-9/DSM-IV-TR The provider will receive a fax notifying him/her of the denial. A denial letter with appeal rights will be mailed to the provider.

19 Reasons for a Modification or Denial of Services Modification of Services Dates of service – Retro authorization Number of units for CPT Codes that do not meet medical necessity Denial of Services Incorrect DSM-IV-TR Code Duplication of services

20 Claims Department Sonia Lopez- Director of Claims

21 Submission Process

22 THIN Payer ID # P:\EDI Enrollment (Electronic Claims Submission)\THIN EPFirst EDI Payer NamePayer ID Medicaid-TX Premier Plan (STAR HMO)EPF02 El Paso First- CHIPEPF03 Preferred AdministratorEPF10 Healthcare Options / Care ManagementEPF37

23 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


25 CMS 1500

26 Additional Information Rejection Form

27 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..

28 Member Service Helpline (915)-532-3778 or 1-877-532- 3778 Office Business Hours Monday- Friday 8:00 AM – 5:00 PM Hours of call center operation 7:00 AM – 6:00 PM After Hour on call 24 hours a day 7 days a week.

29 El Paso First Programs El Paso Premier Plan/STAR ∙ ∙ El Paso First Premier Plan - STAR Medicaid Program ∙ ∙ Medicaid is a program that offers health and long-term care services to certain persons who have limited income, are pregnant, and/or persons with disabilities El Paso First CHIP (Children’s Health Insurance Program) ∙ A program designed for families who earn too much money to qualify for Medicaid, yet can not afford to buy private insurance. ∙ Membership includes children ages 0-19 & enrollment for 12 months ∙ Certain services may require CHIP member co-payments

30 El Paso First Programs El Paso First CHIP Perinatal Program ∙ ∙ CHIP Perinatal provides prenatal care to unborn children or pregnant women up to 200% of FPL and who are not eligible for Medicaid or traditional CHIP. ∙ ∙ The unborn child is enrolled in CHIP Perinatal and once born, will receive full CHIP benefits for the duration of the 12 month coverage period ∙ ∙ CHIP Perinatal members have no co-payments Preferred Administrators ∙ ∙ El Paso First Health Plans, (dba Preferred Administrators) is the Third Party Administrator (TPA) for the El Paso County Hospital District. Preferred Administrators is the TPA that manages the health care benefits for the County Hospital District.

31 El Paso First Health Plans Behavioral Health & Substance Abuse Crisis Line For behavioral, personal, family problems and substance abuse such as alcohol or drugs. (915) 351-1264 or 1-866-944-6467 Crisis Line available 24/7/365

32 Questions???

33 Employee Assistance Program

34 Sun City’s Mission Improve the availability and quality of behavioral health services in El Paso Ensure that our EAP services are being delivered in the most effective and efficient manner Provide our EAP members with an array of choice for mental health & substance abuse services, as well as the convenience to access a provider close to home, school, or work

35 Sun City’s New Location Sun City Behavioral Health Care » 2929-B Montana Ave El Paso, Texas 79903 » Phone # 915-351-4680 » Fax # 915-351-3643 From: Sun City Behavioral Health Care 616 N. Virginia St El Paso, Texas 79902

36 Sun City Behavioral Health Care Our New Location!! We are right across from Police Headquarters on Montana Located inside the “Sun City Medical Plaza”

37 Behavioral Services Over 215 Behavioral Health Providers available – Licensed Professional Counselors – Licensed Marriage & Family Therapists (LMFT) – Licensed Clinical Social Workers (LCSW) – PhD level Psychologists – Psychiatrists (Child & Adult) Offer 3 to 8 sessions per year (dependent on the plan chosen by the employer)

38 High Quality of Services Extensive choice of providers – Conveniently located throughout the El Paso County Licensed professionals – Undergo strict credentialing process Recognized in the local community for their quality of service Offer approximately 130 counselors that can provide counseling in English & Spanish (Other counselors fluent in French, German, Hebrew, and Russian)

39 Sun City EAP Process – EAP Referral Letter from Sun City Includes name (s) of eligible members Member must provide on day of initial assessment – Pre-Authorization Fax Form Must be filled out by provider Faxed to 915-351-3643 Sun City will return authorization within 7 days – Discharge Summary Must be completed by provider within 2 weeks after discharge Faxed to 915-351-3643


41 What are Mandatory Referrals? At times, the employer may find it necessary to obligate the employee to attend counseling on a mandatory basis. Typically Mandatory referrals are the result of absenteeism, substance abuse, violation of company policy and procedures, etc. Employers require compliance with treatment recommendations and can be requested on a weekly, bimonthly, or monthly basis.


43 Follow up Program Our standard follow up program will be conducted, by a Sun City Representative, 3 months after the member has been discharged from the provider The member will be asked to rate Sun City EAP on the following areas 1.Accessibility 2.Referral Process 3.Satisfaction with Provider/Treatment 4.Overall Satisfaction with EAP Program


45 Claims Process Claims should be submitted to Sun City within 30 days of the date of service. All EAP Claims will be processed for payment within 30 days of receipt.

46 Discharge Summary Sun City will begin supplying all EAP providers with a “ Discharge Summary” Discharge Summary: – HIPPA Compliant – Needs to be faxed to Sun City within 2 weeks of the member’s discharge from your program


48 1.Call 1-877-560-8730 (Toll-Free) or 915-351-4680 (Main Office) 2.Describe your concerns to Care Coordinator 3.Care Coordinator will evaluate your situation 4.An appropriate plan will be developed for you 5.You will be linked to the appropriate Provider 6.Care Coordinator will provide you with coordination and guidance while accessing EAP services 7.You will receive a referral letter to take to the provider to receive the services 8.If long term services are needed, the Care Coordinator will assist you in accessing your insurance benefits or referring you to community resources 9.Follow-up will be provided to ensure that all your needs were met How do Employees access their EAP benefits?

49 Who is eligible for Sun City EAP services? – Employee – Immediate family members – Dependents When are Sun City EAP services available? – Monday – Friday – 8:00 – 5:00 – Crisis Line * 24 hrs a day 7 days a week How much will Sun City EAP cost me? – Your behavioral services have been pre-paid by your employer so they are free of charge to you – Other services are offered at discounted rates Frequently Asked Questions

50 Employee Confidentiality is protected by Federal Law. All calls, accessibility of service and counseling sessions are strictly confidential. All records are kept at Sun City Behavioral Health and do not go to your employee file.

51 Sun City reevaluates the past and faces the present while preparing for the future. We are here to assist you

52 Thank You!

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