El Paso First Team Provider Relations Department  Frank Dominguez – Director, Provider Relations and Contracting  Michelle Anguiano – Provider Relations THSteps Coordinator Health Services Department  Jim Voiland, MBA, MSN, RN – Health Services Director  Janel Lujan, LMSW– Case Management Coordinator Claims Department  Sonia Lopez – Claims Director

Agenda  Provider Relations Overview  Healthx Fax System  Substance Abuse Treatment Benefits  Provider Care Unit (PCU)  Claim Submission and Appeal Process  Q/A

Provider Relations Overview Provider Relations Department

Eligibility Verification Claims Information Authorization Information 24 hours a day 7 days a week Call STAR/Premier Plan CHIP and CHIP Perinate Health Care Options Indigent Program Third Party Administrator Commercial Plan Provider Relations and Contracting Department  Liaison Between Network Providers, Health Plan and State Regulators (HHSC and TDI)  Network Development (Recruitment)  Provider Education

Eligibility Verification Claims Information Authorization Information 24 hours a day 7 days a week Call STAR/Premier Plan, CHIP and CHIP Perinate

Eligibility Verification Claims Information Authorization Information 24 hours a day 7 days a week Call STAR/Premier Plan CHIP and CHIP Perinate Health Care Options Indigent Program Third Party Administrator Commercial Plan EL Paso First Website El Paso First Website: Provider Relations Hotline: ext 1507 Access Provider Manual, Provider Directories and Forms Provider Newsletter Provider Forms (Authorization List, Demographic Update, etc.) Links Waste, Abuse and Fraud Educational Link TMHP Provider Procedures Manual CHIP, STAR, and CHIP Perinate Provider Manual CHIP Health Benefit Plan-Evidence of Coverage CHIP Perinatal Program for Unborn Children-Evidence of Coverage Waste, Abuse and Fraud Educational Link TMHP Provider Procedures Manual CHIP, STAR, and CHIP Perinate Provider Manual CHIP Health Benefit Plan-Evidence of Coverage CHIP Perinatal Program for Unborn Children-Evidence of Coverage

Provider Relations Department Contact Information: Frank DominguezDirector of Provider Relations and Contracting ext Irma HerreraProvider Relations Supervisor ext Evelyn LopezContracting Representative ext Cindy AvalosContracting Representative ext Cynthia MorenoProvider Relations Representative ext Michelle AnguianoTHSteps Coordinator ext Rene DuranProvider Relations Representative ext Maritza LopezProvider Relations Representative ext Oscar GonzalezProvider Relations Representative ext

Questions? Thank You!!!

Pre-Authorization Overview  Substance use treatment services  Pre-authorization requirements  Behavioral health pre-certification form  Frequently asked questions  Case management  El Paso First crisis line

Substance Use Treatment Services  Outpatient substance abuse treatment services will become effective September 1, assessment ambulatory detoxification counseling medication assisted therapy  Residential benefits will become effective January 2011 (pending federal government approval). Residential detoxification and treatment

Pre-Authorization Requirements  Initial evaluations do not require an authorization  Subsequent visits require an authorization  Behavioral Health Unit will process authorizations within 72 hours

Substance Use Benefits Available September 1, 2010 Assessment – Billing code: H0001 – Does not require prior authorization Outpatient individual counseling – Billing code: 9-H0004 – Requires prior authorization Outpatient group counseling – Billing code: 9-H0005 – Requires prior authorization Ambulatory (outpatient) detoxification – Billing code: 1-H0014 – Requires prior authorization

Substance Use Benefits Available September 1, 2010 Medication Assisted Therapy (MAT) – MAT for opioid addiction when using methadone Billing code: 1-H0020 Requires prior authorization — MAT for opioid addiction when using drugs other than methadone Billing code: 1-H2010 Requires prior authorization – MAT for treatment of non-opioid addiction Billing code: 1-H2010 Requires prior authorization

Substance Use Benefits Available January 1, 2011 Residential treatment – Billing code: 1-H0011 – Requires prior authorization Residential detoxification – Billing code: 1-H0047, 1-H2036 (per diem) – Requires prior authorization

Pre-Authorization Requirements BENEFITS AVAILABLE 09/01/10 PRIOR AUTHORIZATION & LIMITATIONS BILLING CODES Assessment No H0001 Medication Assisted Therapy (MAT)* MAT for opioid addiction with methadone Yes 1-H0020 MAT for opioid addiction with drug other than methadone Yes 1-H2010 MAT for non-opioid addiction Yes 1-H2010 Outpatient individual counseling Yes 26 hours/calendar year 9-H0004 Outpatient group counseling Yes 135 hours/calendar year 9-H0005 Outpatient detoxification Yes 1-H0014 BENEFITS AVAILABLE 01/01/11 PRIOR AUTHORIZATION & LIMITATIONS BILLING CODES Residential detoxification Yes 1-H0011 Residential treatment Yes 35 days 1-H0047, 1-H2036 (per diem)

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...”

Pre-Certification Form

Pre-Certification Form (pg. 2)

Pre-Authorization: FAQ’s  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 , 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)

Texas Health and Human Services Commission HHSC Reference:

Behavioral Health Case Management  Team of nurses and social workers assist with the following:  Access and coordinate services  Integrate care for individuals with a dual diagnosis  Provide referrals to community resources for basic needs  Referrals are accepted by the Case Management Coordinator at (915) or extension 1090

El Paso First Crisis Line  El Paso First members have access to crisis intervention services 24 hours a day, 7 days a week  El Paso First Premier members may call  El Paso First CHIP members may call

Questions Janel Lujan, LMSW Case Management Coordinator (915) Extension: 1090

Claims Department Claim Submission

Verification of Authorization Remember to Bill with valid Diagnosis Codes BOX 21 Remember to Point your Diagnosis code to the appropriate Service BOX 24E Claims Submission Submit Your Claim:  Hand Written and Typed to El Paso First Health Plans - Claims P.O. Box El Paso, TX  El Paso First Web Portal at  Electronic Billing via Clearinghouse  To access the EDI Form please go to our website at

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

Submission Process STEP (1) How can a provider submit claims electronically? – The provider may log into the El Paso First Web Portal accessible through the El Paso First Website – The provider may submit batch claims through a clearinghouse STEP (2) What happens when the claims are received at the clearinghouse? – When claims arrive to the designated clearinghouse the claims will be scrubbed by the clearinghouse for HIPPA edits. Any claims that do not pass HIPPA edits will be rejected by the clearinghouse up front and the plan will never received the claims. – The clearinghouse will send a response back to the provider with any claim rejections and error message. The provider will need to correct the claims and resubmit. – All claims that pass the clearinghouse HIPPA edits will then be transferred to the carrier (El Paso First Health Plans).

Submission Process STEP (3, 4, 5) What happens when the claims are received at the carrier (El Paso First Health Plans)? – El Paso First imports all batch files received from the clearinghouse daily. – The El Paso First import system will run the claims through system edits. – Any claims that do not pass the El Paso First system edits will be rejected and returned back with a response report (997 text file) back to the clearinghouse. – The clearinghouse will then transmit the information back to the provider for corrections. The provider will need to correct the claim and resubmit. – All claims that pass the system edits will import into the core claims processing system.

Submission Process STEP (6, 7, 8)What happens when the claims are imported to the El Paso First claims processing system? – All imported claims will run through auto adjudication on a nightly basis. – 80 percent of the claims will auto adjudicate and pay/deny – 20 percent of the claims will adjudicate and Pend for manual review

CMS 1500

CMS 1450 UBO4

To Check Claim Status  Providers may utilize the following resources:  Web portal account (  HealthX Fax System at (24 hours a day 7 days a week)  Call the Provider Care Unit at extension 1504

Claim/Appeal 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..

Provider Care Unit and how it works Contact us at When calling you will reach a Claims specialist who will:  Give claim status calls.  Resolve or answer claim questions.  Answer Electronic claims submission rejections or questions.  Assist with claims disputes.  Corrected Claims

Complaints and Appeals Complaint Process :  Acknowledgement  Resolution  What is a level 1 Appeal  What is a level 2 Appeal Please note you have the right to appeal any disposition of a claim through a formal appeal. Written request must be mailed to: El Paso First Health Plans, Inc Attn: Complaints and Appeals Department POBOX , El Paso, Texas Within 120 days from the date of your Provider Remittance Advice.

Questions? Thank you for your attendance!