Effective May 2013 - El Paso First Health Plans, inc.

INPATIENT ADMISSIONS:
All elective (non-emergency) admissions require prior authorization. The prior authorization process will review
the medical necessity and appropriateness for the requested admission. Prior authorization will also identify
appropriate alternative facility providers or settings for the requested admission, such as an alternative use of an
outpatient facility when the requested service can be safely and effectively done in an outpatient rather than an
inpatient setting.
All emergency admissions (those through an Emergency Room or a direct admit from a physician’s office) require
notification within twenty four (24) hours or the next business day following the emergency admission. Failure
to notify Preferred Administrators of an emergency admission will result in denial of a claim. When emergency
admissions occur and the patient will be confined beyond twenty four (24) hours, transfer to UMC will be
offered when the patient's condition can appropriately be treated at UMC and the patient is medically stable
and able to be transported to UMC.
Although is the Provider’s responsibility to request authorization for the health care services to be delivered, it is
ultimately the Associate’s responsibility to ensure that the requested services have been preauthorized to avoid
delay in services or unpaid claims. We encourage you to always call Preferred Administrators at 915-532-3778
to verify if the provider requested an authorization before your render the services.
Note: Preauthorization is not a guarantee of eligibility for benefits or payment. Please refer to the covered
benefits section.
CONCURRENT REVIEW AND DISCHARGE PLANNING:
All inpatient admissions are monitored for compliance with the certified length of stay. Admissions which are
continued beyond the expected length of stay, are reviewed to determine the medically necessity for the
continued stay, and to identify the expected discharge date of the patient.
The Preferred Administrators Case Manager will work collaboratively with the facility when a patient can
appropriately be transferred to an alternative care setting; or when a patient is discharged from an acute care
setting to an alternative care setting such as home health care.
MATERNITY:
Covered Associates are asked to contact the Preferred Administrators OB Unit at 915-532-3778 ext. 1500 as
soon as the initial diagnosis of pregnancy is made by the physician. The OB Case Manager will ask for basic
information like the expected delivery date and the facility where the Associates anticipate delivery.
INPATIENT MATERNITY:
All Inpatient Maternity admissions require notification from your provider within twenty four (24) hours or the
next business day following the delivery. Failure to notify Preferred Administrators of an emergency admission
will result in complete denial of a claim.
UMC BEHAVIORAL HEALTH CARE:
All UMC Employees can receive Employee Assistance Program (EAP) services that include, but are not limited to,
mental health and substance abuse services. The Employee Assistance Program (EAP) offers 8 free counseling
sessions for therapy and counseling by providers within the EAP Program. If you require more than 8 professional
services a Prior Authorization will be required. You can call the EAP program at 915-351-4680 to make your
appointment. Members can also contact Preferred Administrators to access these services by calling 915-532-
3778 or 1-877-532-3778 (if outside the calling area). Participating behavioral health care providers are listed in
the back of this directory.
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Customer Service Helpline
915-532-3778 or 1-877-532-3778