1. WELCOME
PROVIDERS
Thursday , February 25, 2010

2. Chief Executive Officer
El Paso First Health Plans, Inc.
Chief Executive Officer
Carol Smallwood

3. Provider Relations Department
Updates

4. Electronic Fund Transfers/ New Demographic Form

5. Provider Relations - SURVEY

6. PCP ROSTERS (New Feature)

7. 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ICD 9 – outdated over 30 years old, technological changes, not descriptive enough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

8. Health Services Department
Jim Voiland – Director of Health Services

9. 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

10. Quality Improvement Committee
and Sub-Committees
QUALITY IMPROVEMENT
COMMITTEE
(QIC)
PHYSICIAN ADVISORY
(PAC)
CREDENTIALING AND
PEER REVIEW
(CPRC)
UTILIZATION
MANAGEMENT
(UMC)
OPERATIONS
IMPROVEMENT
(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. Da
M. 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, RN
Carol Smallwood (Chairman)
CEO/President C
Colleen Grady, RN
Manager of Quality Improvement
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
*Irma Vasquez
(Health Services Administrative Supervisor)

12. 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)

13. 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.
*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 Director
Jose 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 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)

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
Responsibilities
Meeting Times
Quality 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 occur
Centralizing and coordinating the integration of all quality improvement activities
Adopting national and local practice guidelines and clinical standards of care and policies of medical practice.
Analyzing and evaluating summary data.
Quarterly
Credentialing and Peer Review Committee (CPRC)
Credentialing and Recredentialing
Corrective Action Plans, Medical Record Reviews
Approving office site visit forms and procedures.
Resolution of Clinical issues that affect members’ health status.
Monthly
Utilization 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 process
Reviewing 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 needed
Operations 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.

18. 24 hour Availability & Office Accessibility Surveys

19. We will select a random sampling of the provider pool every quarter.
Surveys
The 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 Results
Specialty
1st
Qtr
2nd Qtr
3rd Qtr
4th Qtr
Family Practice 10 13 12 7
Internal Medicine 8
OB-GYN 9
Pediatrics 11
Psychiatry 5 1
Psychology
Total Physicians Surveyed
24-hour
Office
Met
Not met
Not Met
148 55 93
108 40
*A total of 168 providers were contacted , 12% have moved out of
town or are no longer at location contacted.

21. Total Physicians Surveyed
SFY st Quarter Results
Specialty
1st
Qtr
2nd Qtr
3rd Qtr
4th Qtr
Family Practice 10
Internal Medicine
OB-GYN
10*
Pediatrics
Total Physicians Surveyed
24-hour
Office
Met
Not met
Not Met 39 22 17 31 8
*An OB/GYN Provider was contacted and
is no longer in practice

22. Member Services Department
Edgar Martinez – Director of Member Services

23. Member Service Helpline
(915) or
Medicaid/STAR ext. 1514
CHIP ext. 1517
Preferred Administrators ext. 1529
Health Care Options (HCO) ext. 1502
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

24. 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

25. 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

26. By Michelle Anguiano Provider Relations THSteps Coordinator
THSteps Updates
By Michelle Anguiano
Provider Relations
THSteps Coordinator

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 Guidelines
Genetic Screening
Case Management
Oral Health
Developmental/Mental Screening
Prevention & Wellness
Adolescent Health
Overview of Best Practices and Children’s Services
Sensory Screening
Laboratory Services
Acute & Chronic Mental Conditions
Pharmacy
For 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.
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.
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:     –     –     –     – 99392
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:

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 Information
If you have any questions or concerns please contact me at:
Phone: (915) extension 1053.

36. Sonia Lopez – Director of Claims
Claims Department
Sonia Lopez – Director of Claims

37. 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. .

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 date
Individual claim that is being appealed
EL 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 code
Composite 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 participation
and have a great day!