Welcome Providers - El Paso First Health Plans, inc.

Welcome Providers
Thursday, November 11, 2010
Page 1

What is a 3 Share Plan?
•The 3 Share Plan is an affordable health plan for small businesses.
•Cost is shared among employers, their employees, and one or more
sources of local, state, or federal funding.
•Mission is to encourage employers to provide healthy work sites and
employees to embrace healthier everyday choices at an affordable low
premium cost.
Regional Programs:
http://texhealth.org/index.php

TexHealth El Paso County
TexHealth El Paso will provide a quality affordable healthcare coverage
benefit plan to the working uninsured of El Paso County.
Collaborative efforts will help to:
• improve the healthcare of those covered
•assist small businesses in remaining competitive with the healthy
workforce
•assist to bridge the gap of those who are uninsured.
Healthcare benefits include:
Free Annual Physical
Free Health Risk Assessment
Doctor Visits and Specialty Care
Emergency Room, Inpatient, Outpatient
Hospital
Pharmacy, Lab, X-ray
Maternity Care
Wellness and Care Coordination

Low Premiums
With Premium assistance grants qualified employees may pay as little as
$12.00 per month for comprehensive health coverage plan.
Business Employer Qualifications
Many small business employers will have employees eligible for assistance.
•Businesses or organizations with 2 to 50 employees.
In business for at least one year prior to enrollment, and have not
offered group health insurance during the last 12 months.
If your business is interested in having this benefit plan for your
staff, please contact :
Les C. Rankin Director TexHealth 3-Share Plan
Office: 915.521.7838 Cell: 915.472.4064
lrankin@umcelpaso.org Fax: 915.521.7689

ER Reports
• Purpose
– Help Primary Care Providers identify members from their
panel that go to the ER to seek care
– Provide education on true emergencies and give options of
care other than the ER like After Hours and Night Clinics.
– To provide them with a Medical Home.
• Content
– Member name, ID number, Age, DOB, Phone
number, Address, ER DOS, ER Location, Diagnosis.
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ER Reports
• Time frame
– Initial mail out effective December 1, 2010 will
reflect 6 months worth of information.
– Attached to STAR Rosters after the initial mailing
every month.
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SAMPLE ER REPORT

Texas Health Steps Updates
Michelle Anguiano
Provider Relations THSteps Coordinator

Billing Medicaid Members
Source: TMHP 2010 Provider Procedures Manual

Billing Medicaid Members
Source: TMHP 2010 Provider Procedures Manual

Billing Medicaid Members
Source: TMHP 2010 Provider Procedures Manual

THSteps Checkups Concerns
• THSteps checkups to new members (within
90 days of enrollment)
– State requirement
– For vaccinations not recorded on ImmTrack- Provider’s
decision
Audit results and highlights
– Lack of documentation of Anticipatory Guidance
– Lack of documentation of Newborn Screenings
– Lack of use of THSteps Tools (Mental Health)

Changes in the Timeliness of THSteps
Medical Checkups
• Effective for dates of service on or after
September 1, 2010, the definition of the
“timeliness” of Texas Health Steps (THSteps)
medical checkups will change for clients who
are 3 years of age or older. Children who are
birth through 2 years of age will still be due for
medical checkups more frequently and will
not be affected by this change.
Source: TMHP website
http://www.tmhp.com/homepage%20File%20Library/07-09-10%20Changes%20in%20the%20Timeliness%20of%20THSteps%20Medical%20Checkups.pdf

What does not change?
• While the change in the definition of timeliness only applies
to children 3 years of age and older, a claim for a medical
checkup can be submitted based on the total number of
checkups that can be provided in each age range below. This
allows a provider to perform one THSteps checkup per year
for a child 3 years and older and submit a claim and still
receive reimbursement, even for a checkup performed prior
to the birth date/due date.
Source: TMHP website
http://www.tmhp.com/homepage%20File%20Library/07-09-10%20Changes%20in%20the%20Timeliness%20of%20THSteps%20Medical%20Checkups.pdf

Exceptions to Periodicity
• Exceptions are based on medical need such as
– developmental delay,
– environmental risk,
– suspected abuse,
– or state and federal requirements for Head Start, day care, foster care or
adoption,
– or for dental services under general anesthesia
– If they client will not be available at the time the next checkup is due such
as the case of children of migrant farm workers
– If the provider is aware that the child is not due for a checkup based on
age and the date of the last checkup or their Medicaid 3087 form does not
state that the client is due the visit must be submitted as an exception to
periodicity.
(TMHP Provider Procedures Manual 43-9)

Exceptions to Periodicity
• When billing for an exception to periodicity visit, provider must also include the most
appropriate exception to periodicity modifiers.
• Claims for periodic THSteps medical checkups exceeding periodicity that do not include
one for these modifiers will be denied as exceeding periodicity.
Source: THMP Provider Procedures Manual 2009 Section 43.1.7.7

Developmental Screening Tools
(ASQ and PEDS)
• 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
http://www.epfirst.com/ProvidersEPSTD.html

Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Change http://www.tmhp.com/txtlstvw.aspx?LstID=b48ca997-4760-4d81-9401-5f92a493dd5d

Provider Relations Department THSteps
Tools
• Monthly Members Due List
– Sent with STAR Roster to ALL PCPs
– Existing
– New Members
• Missed Appointment Referral Sheet
– Reduce the number of missed appointments
– Assist provider office staff with the issues missed
appointments may create.
• You can access more tools when logging to our website at
http://www.epfirst.com/ProvidersEPSTD.html

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 http://www.txhealthsteps.com/

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.
• 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.
• To register please go to:
http://www.dshs.state.tx.us/dental/OEFV_Training.shtm

Contact Information
– Michelle Anguiano
• E-mail: manguiano@epfirst.com
• Phone: (915)298-7198 extension 1053.

El Paso First – OB Benefits
Edna Martinez, LMSW
OB Case Manager

First Steps-OB Team
OB Team
Edna Martinez - OB CM
Edna Martinez - OB CM
Gloria McMillan - UR Tech
Gloria McMillan - UR Tech
Norma Hollars – Prior Auth Coord.
Norma Hollars – Prior Auth Coord.
El Paso First Health Plans
promotes community
health by providing access
to quality healthcare for
children, families and
individuals who need it
most. We partner and
collaborate with
community providers and
advocate to foster a
culture of excellence.
El Paso First Health Plans
promotes community health by
providing access to quality
healthcare for children, families
and individuals who need it
most. We partner and
collaborate with community
providers and advocate to
foster a culture of excellence.

Benefits
Doctor visits
Hospital (Inpatient/
Outpatient)
Ambulance Services
Dental care (under 21 only)
Family planning
Transportation
Emergency Services
Ambulatory Health Care
Services
Lab Services
Vision
Well-Baby and Well Child
Visits
Immunizations
Inpatient and Outpatient
Mental Health Visits

El Paso First – Extra Benefits
$15 Welcome Packet
Transportation (taxi rides)
Asthma, Diabetes, and
Prenatal Health Education
Classes
$20 Wal-Mart gift card
Free Gift
Quarterly Newsletter

El Paso First – Extra Benefits
Ultrasounds
El Paso First Members
can receive four
ultrasounds without
prior authorization.

El Paso First members are invited to our baby
shower/ prenatal class

El Paso first members may receive
a $20.00 wal-mart gift card

Member Services Department

El Paso First CHIP Plan (CHIP)
•$15 Welcome packet with OTC medications.
•Preventive Dental Services for pregnant members.
•Additional 25% discount toward the purchase of
lenses and frames
•Additional 20% discount toward the purchase of
disposable contact lenses.
•Free Transportation for medical appointments.
•Additional nutritional counseling services for
members age 18 and under.
•Gift Programs (new)

El Paso First CHIP Perinatal Plan
(CHIP Perinatal)
•$15 Welcome packet with OTC
medications.
•Free Transportation for
medical appointments.
•Gift Program (new)

El Paso First Premier Plan (Medicaid)
•$15 Welcome packet with OTC medications.
•Preventive Dental Services for pregnant
members over 21 years of age.
•Eyeglasses valued up to $125
•Free Transportation for medical appointments.
•Additional nutritional counseling services for
members under 21 years of age.
•Additional Behavioral Health services.
•Gift Programs (new)

El Paso First Premier Plan
Happy Birthday Gift Card Program
THSteps VAS Initiative (Medicaid Only)

Children of Migrant Farm Workers Program
El Paso First has special Medicaid services for children of migrant farm
workers:
•We help schedule THSteps Medical Checkups appointments
•Assist with accelerated THSteps medical services for migrant members
•Vision Benefits
•Mental Health Services
•Transportation

Claims Department
Sonia Lopez
Claims Director

CLAIM DENIALS
How To
Preventing
Claim Denial

EP First Top Denials
Description
Totals
Duplicate Claim 15,060
Timely Filing 12,524
Member Not Enrolled 11,019
Member is SSI Enrollment 7,659
NPI is Invalid / Incomplete 4,084

CLAIMS DEPARTMENT
Important Claim
Elements
for
Paper and Electronic
Claim Submission

Billing Provider –NPI Provider LOOP
2010AA
1500
Item
Number
Paper Claim
Field
Description
ANSI 837 Loop &
Segment
Electronic Claim Field
Description
25
Federal Tax ID
Type 2010AA NM108 Provider Tax ID Type
25
Federal Tax ID
Number
2010AA NM109
Provider Tax ID Number

Billing Provider –NPI Provider LOOP
2010AA
1500
Item
Number
Paper Claim
Field
Description
ANSI 837 Loop &
Segment
Electronic Claim Field
Description
33a
Billing Provider
Info & PH # 2010AA NM109 Billing Provider - NPI
33b 2010AA REF02 Billing Provider Tax ID or TPI #
Submit Group NPI Only in Loop 2010AA
Place Group NPI ONLY in Box 33a

Rendering Provider LOOP 2310B
1500
Item
Numb
er
Paper Claim Field
Description
Ansi 837 Loop
& Segment
Electronic Claim Field
Description
24I ID Qualifier 2310B NM108 ID Code Qualifier
ID Qualifier (Other )
2310 REF 01 ID Code Qualifier (Other ID No.)
ID Qualifier NPI 2310B NM108 ID Code Qualifier (NPI)
Submit Rendering’s INDIVIDUAL NPI Only in Loop 2310B
Place Rendering’s INDIVIDUAL NPI ONLY in Box 24J
24J
Rendering Provider
ID #
2310B NM109
2310B REF02
Rendering Provider NPI
Rendering Provider Secondary ID

Provider Care Unit (PCU)

Contact us at 532-3778
Provider Care Unit
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.
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 971370, El Paso, Texas 79997-1370
Within 120 days from the date of your Provider Remittance Advice.

Claims Status By Phone
Local:
(915) 225-5463
Toll Free:
(866) 283-2792

Verification of Authorization
FY 2010
•Remember to Bill with valid Diagnosis Codes
BOX 21
ember to Point your Diagnosis code to the appropriate
Service BOX 24E
Claims Processing
Benchmarks

Electronic Claim Growth
YR 2006 YR 2007 YR 2008 YR 2009 YR 2010
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC

Electronic Claim Volume
Portal Users, 1.4%
Manual Users, 18.4%
Electronic Users
Manual Users
Portal Users
Electronic Users, 80.1%

CONDITION INDICATOR CODES
Auto Adjudication Ratio
Auto Adju Ratio
Manual Adju Ratio
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Questions?