2 Please Note: El Paso, Tx 79925-5615 Paper claim submissions will continue to go to:El Paso First Health Plans –ClaimsP. O. BoxEl Paso, TxOur general correspondence address will not change:P.O. BoxEl Paso, Tx1145 Westmoreland DriveEl Paso, Tx
3 El Paso First Departments Contact Information Main number:DepartmentExtensionFax numberDescriptionMember ServicesSTAR STAR Sp1518 CHIP CHIP Sp 1519 HCO 1502 TPA 1529EligibilityHealth Services1500(pre-authorizations)Pre-authorizations & Case ManagementPCUPCU-1504Claims status & Corrections
4 Provider InformationIn order to have the most updated/ accurate information in our system and in our directories please provide any type of changes to Sun City.
5 El Paso First Health Plans Behavioral Health Unit Health Services Department
6 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
7 Pre-Authorization Requirements Initial evaluations do not require an authorization(CPT Code 90801)Subsequent visits for individual and/or family visits require an authorization
8 Pre-Authorization Requirements Pre-Certification form must be faxed to the Behavioral Health Unit at for all inpatient and outpatient requestsBehavioral Health Unit will turn around authorizationswithin 72 hours
9 Pre-Authorization Process Flow Provider faxes El Paso FirstPre-certification form is submitted for all inpatient/outpatient requestsFax number:El Paso First begins review processMulti-axial informationCurrent symptomsResponse to past treatmentTreatment goalsCPT Codes, units and frequencyMedical director makes determinationFinal determination based on medical necessityProvider will receive a fax with decision
10 Pre-Authorization Process Flow Providers may call the Behavioral Health Unit directly for questions regarding the status of the authorization requestContact informationx 1500
13 Completing the Pre-Certification Form Complete the member’s identifying information so an authorization can be generatedMember’s nameHealth plan identification numberDate of birth
14 Completing the Pre-Certification Form For initial requests, please provide a brief narrative of the member’s clinical presentationThis information should be entered under “Evaluation of initial treatment”For continuation requests, please include a summary of why services need to continueThis information should be included under “For continuation of therapy requests . . .”
15 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 facilityDate of procedure – The date the provider is going to conduct the requested CPT Code (i.e , 90847)Do I fill out CPT Codes or Revenue Codes (Rev Codes)?CPT Codes are common for most outpatient providersRevenue Codes are used by facility providers (i.e. psychiatric hospitals)
16 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 necessityHow much information is necessary for the pre-certification form?Brief description that paints a clinical picture of the individualUpdated clinical information is important for continuation requests
17 Modification of Services Denial of Services The Medical Director has approved services with a modification from the original requestExample:Provider requests date of service from 01/29/10 – 11/10/10Medical Director approves a date of service from 01/29/10 – 04/29/10The provider will receive a fax notifying him/her of the modification and an opportunity to discuss the services that were not approvedThe Medical Director has not approved the requested servicesExample:No clinical information is submitted with the pre-certification formIncorrect ICD-9/DSM-IV-TRThe provider will receive a fax notifying him/her of the denial. A denial letter with appeal rights will be mailed to the provider.
18 Reasons for a Modification or Denial of Services Modification of ServicesDenial of ServicesDates of serviceRetro authorizationNumber of units for CPT Codes that do not meet medical necessityIncorrect DSM-IV-TR CodeDuplication of services
19 Claims Department Sonia Lopez- Director of Claims
21 Medicaid-TX Premier Plan (STAR HMO) Preferred Administrator THIN Payer ID # P:\EDI Enrollment (Electronic Claims Submission)\THIN EPFirst EDIPayer NamePayer IDMedicaid-TX Premier Plan (STAR HMO)EPF02El Paso First- CHIPEPF03Preferred AdministratorEPF10Healthcare Options / Care ManagementEPF37
22 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
26 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..
27 Member Service Helpline (915) orOffice Business Hours Monday- Friday 8:00 AM – 5:00 PMHours of call center operation 7:00 AM – 6:00 PMAfter Hour on call 24 hours a day 7 days a week.
28 El Paso Premier Plan/STAR El Paso First ProgramsEl 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 disabilitiesEl 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
29 Preferred Administrators El Paso First ProgramsEl 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-paymentsPreferred 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.
30 Crisis Line available 24/7/365 El Paso First Health Plans Behavioral Health & Substance Abuse Crisis LineFor behavioral, personal, family problems and substance abuse such as alcohol or drugs.(915) orCrisis Line available 24/7/365
33 Sun City’s MissionImprove the availability and quality of behavioral health services in El PasoEnsure that our EAP services are being delivered in the most effective and efficient mannerProvide 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
34 Sun City’s New Location Sun City Behavioral Health Care2929-B Montana AveEl Paso, Texas 79903Phone #Fax #From: Sun City Behavioral Health Care616 N. Virginia StEl Paso, Texas 79902
35 Our New Location!!Sun City Behavioral Health CareWe are right across from Police Headquarters on MontanaLocated inside the “Sun City Medical Plaza”
36 Behavioral Services Over 215 Behavioral Health Providers available Licensed Professional CounselorsLicensed Marriage & Family Therapists (LMFT)Licensed Clinical Social Workers (LCSW)PhD level PsychologistsPsychiatrists (Child & Adult)Offer 3 to 8 sessions per year (dependent on the plan chosen by the employer)
37 High Quality of Services Extensive choice of providersConveniently located throughout the El Paso CountyLicensed professionalsUndergo strict credentialing processRecognized in the local community for their quality of serviceOffer approximately 130 counselors that can provide counseling in English & Spanish (Other counselors fluent in French, German, Hebrew, and Russian)
38 Sun City EAP Process EAP Referral Letter from Sun City Includes name (s) of eligible membersMember must provide on day of initial assessmentPre-Authorization Fax FormMust be filled out by providerFaxed toSun City will return authorization within 7 daysDischarge SummaryMust be completed by provider within 2 weeks after discharge
40 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.
42 Follow up ProgramOur standard follow up program will be conducted, by a Sun City Representative, 3 months after the member has been discharged from the providerThe member will be asked to rate Sun City EAP on the following areasAccessibilityReferral ProcessSatisfaction with Provider/TreatmentOverall Satisfaction with EAP Program
44 Claims ProcessClaims 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.
45 Discharge SummarySun City will begin supplying all EAP providers with a “ Discharge Summary”Discharge Summary:HIPPA CompliantNeeds to be faxed to Sun City within 2 weeks of the member’s discharge from your program
47 How do Employees access their EAP benefits? Call (Toll-Free) or (Main Office)Describe your concerns to Care CoordinatorCare Coordinator will evaluate your situationAn appropriate plan will be developed for youYou will be linked to the appropriate ProviderCare Coordinator will provide you with coordination and guidance while accessing EAP servicesYou will receive a referral letter to take to the provider to receive the servicesIf long term services are needed, the Care Coordinator will assist you in accessing your insurance benefits or referring you to community resourcesFollow-up will be provided to ensure that all your needs were met
48 Frequently Asked Questions Who is eligible for Sun City EAP services?EmployeeImmediate family membersDependentsWhen are Sun City EAP services available?Monday – Friday8:00 – 5:00Crisis Line *24 hrs a day7 days a weekHow much will Sun City EAP cost me?Your behavioral services have been pre-paid by your employer so they are free of charge to youOther services are offered at discounted rates
49 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.
50 We are here to assist you Sun City reevaluates the past and faces the present while preparing for the future.We are here to assist you