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1 , LLC 9702 Bissonnet, Suite 2200W Houston, TX PRESORTED FIRST-CLASS MAIL U.S. POSTAGE PAID MINNEAPOLIS, MN PERMIT NO in focus Evercare of Texas Winter 2008/2009 Volume 8, Issue 1 Please help us obtain accurate contact information. Evercare occasionally corresponds with providers by fax or when we need to communicate important information. Without your updated information, you may be missing important communication materials. Provider Name: Fax Number: address: Locations: Evercare of Texas (Harris Service Area) 9702 Bissonnet, Suite 2200W Houston, TX (Dallas/Fort Worth Service Area) 5800 Granite Parkway, Suite 900 Plano, TX Please complete the information below and fax back to (713) Telephone Number: Tax Identification Number (TIN) Address (Travis Service Area) 1250 Capital of Texas Highway South, Ste. 360 (Bldg. 1) Austin, TX (Fort Worth Service Area) 2630 West Freeway, Suite 207 Fort Worth, TX (Nueces Service Area) 400 Mann Street, Suite 901 Corpus Christi, TX (San Antonio Area) 6200 Northwest Parkway San Antonio, TX In This Issue: Page 2 From the Medical Director Page 3 From the Parent Company UnitedHealthcare Page 4 Top 10 Reasons for Claims Denials Page 5 What May Affect Providers Page 6 Texas Health Steps Page 8 Documentation & Coding Training Page 9 Network Changes Page 10 Electronic Payments Page 11 Children of Migrant Farm Workers Today s News Brought to You by Evercare! We know how difficult it is to keep up with important information from each managed care organization you contract with. That s why Evercare has taken steps to proactively inform you, a member of our provider network, of important information your office needs to know that is specific to Evercare and United Healthcare. Each quarter you will receive a package via U.S. Postal Service mail from Evercare. The package will include some combination of documentation based on your contract type. Typically, the Quarterly Provider Mailing will include the following: STAR + PLUS Provider Directory (for STAR + PLUS providers only) Quarterly newsletter Evercare in Focus Updates to reference materials such as the Quick Reference Guide New information You should have received mailings during the months of June, September, December and February. Please watch for these quarterly news packages and be sure to share them with your staff. We hope you enjoy the information and new communication pieces. Evercare Important Telephone Numbers Customer Service Departments: Evercare STAR+PLUS (Medicaid) Claims status, eligibility, benefit questions, PCP assignments (Nueces service delivery area) Plan DH, Plan IH, Plan MH (Travis and Harris service delivery area) Plan DH, Plan MH Eligibility Verification: Automated line, for all plans Authorization Department: For all plans: Facility inpatient notifications Press 1 Physician office outpatient notifications Press 2 Provider service coordination Press 3 CBA questions/nursing Home modifications Press 4 Authorizations Fax numbers: Preauthorization for Physicians/Facilities: FAX: or etx_um_precert@uhc.com DAHS/Provider Services/Other Requests: FAX: etx_ltc_auth_requests@uhc.com Durable Medical Equipment/Supplies: FAX: etx_dme_supply_auth_req@uhc.com Skilled Services (Nursing/PT/OT): FAX: etx_skilled_in_home_auth_req@uhc.com Provider Relations: For all Evercare plans

2 From the Medical Director Making Health Care More Affordable: A Part-D Perspective By Leslie Cortes, MD Medical Director, Central Texas Patients on a fixed income are challenged by out-of-pocket medication costs. Evercare provides Medicare Part D coverage for its Medicare Special Needs Plan members in an effort to help them obtain clinically effective and affordable medications. The Evercare formulary has multiple tiers, and the lowest and most affordable tier is Tier 1 generics. The co-pay for Tier 2 medications is 7.2 times higher than the co-pay for Tier 1 generics. The co-pay for Tier 3 medications is 14.2 times higher. Not only do Tier 1 medications have the lowest co-pay, but Evercare also covers Tier 1 generics through the Part D coverage gap for members enrolled in the Evercare Chronic Illness Plan. What this means is that if your patient s total medication costs put them in the coverage gap, Evercare will continue to provide Tier 1 generic medications as if there were no coverage gap. In contrast, members on Tier 2 and 3 medications bear the entire cost of those medications. Proton pump inhibitor (PPI) therapy and therapy for hypercholesterolemia are two instances in which Tier 1 generic medications can save your patients money with no sacrifice in effectiveness. Generic omeprazole is a Tier 1 PPI that provides the same efficacy as Tier 2 and Tier 3 PPIs. Similarly simvastatin, pravastatin and lovastatin are Tier 1 generics that are comparable to Tier 2 and Tier 3 agents when the goal of therapy is LDL-C < 130. Medicaid Marketing Guidelines Apply to Providers Texas has established specific marketing guidelines and limitations for Medicaid health maintenance organizations. These guidelines are applicable to the managed care organization, its agents, subcontractors and providers. They ensure that consumers receive accurate and unbiased information. Please familiarize your office with the following marketing guidelines. Policies related to Medicaid Managed Care Program Providers: 1. Providers are permitted to educate and inform their patients about the Medicaid Managed Care (MC) Programs in which they participate. 2. Providers may inform their patients of the benefits, services and specialty care services offered through the managed care organizations in which they participate. However, providers may not recommend one Managed Care Organization (MCO) over another MCO, offer patients incentives to select one MCO over another, or assist the patient in deciding to select a specific MCO. 3. At a patient s request, providers may give the information necessary to contact a particular health plan. 4. Provider must distribute and/or display health-related materials for all contracted MCOs or choose not to distribute and/or display for any contracted MCO: Health-related posters cannot be larger than 16" x 24". Children s books, donated by MCOs, must be in common areas. Materials may have the MCO s name, logo and phone number. When the target LDL-C goal is lower, the use of higher tier agents may be necessary. In contrast to our Medicare plan members, STAR+PLUS members receive their medications from the State s Vendor Drug Program rather than through a Part-D program. Thus, the STAR+PLUS formulary is different from the Evercare formulary for Medicare members. The Medicaid program promotes affordability through its Preferred Drug List and a variety of preauthorization rules that help ensure that the most affordable medication in a class is always used first. I hope that you will work with your patients to find effective medication regimens that will minimize their out-ofpocket medication costs as well as control the societal cost of health care. Providers are not required to distribute and/or display all health-related materials provided by each MCO with whom they contract. Providers can choose which items to distribute or display from each contracted MCO, as long as they distribute or display one or more items from each contracted MCO. 5. Providers must display stickers submitted by all contracted MCOs or choose to not display stickers for any contracted MCOs. MCO stickers indicating the provider participates with a particular health plan cannot be larger than 5" x 7" and cannot indicate anything more than the health plan is accepted or welcomed here. Effective January 1, 2009, the appropriate program logo must be affixed. 6. Providers may distribute Medicaid applications to families of uninsured children and assist with completing the application. 7. Providers may direct patients to enroll in the Medicaid managed care programs by calling the Administrative Services Contactor, MAXIMUS by calling The MCO may conduct member orientation for its members, in a private/conference room at a provider s office, but not in common areas at a provider s office. From Our Parent Company UnitedHealthcare Some Physician Practices Facing National Provider Identification (NPI) Deactivation The Centers for Medicare & Medicaid Services (CMS) has sent letters to health care entities whose legal business names (LBN) in the National Plan & Provider Enumeration System (NPPES) do not match those on file with the Internal Revenue Service (IRS). The NPPES is a system developed by CMS that assigns standard unique identifiers to health care providers. Where practices do not respond to the request, the Internal Revenue Service intends to deactivate those National Provider Identifiers (NPIs). Where practices do not respond to the request, the agency intends to deactivate those National Provider Identifiers (NPIs). If additional information is needed to comply with the request, practices should respond within 15 days to notify CMS of their progress toward remedying the mismatch. To learn more, please visit News. Action Needed per CMS Instructions: 1. If a letter is received from CMS, physician practices should take immediate action to address any mismatch in legal business names 2. To proactively ensure that the physician practice s LBN in the NPPES matches the one of file with the IRS, review your organization s information. Physician practices can also contact the NPI Enumerator at If the physician practice does not know the exact LBN that the IRS has on file, the information can be found by: Checking IRS paperwork, such as a CP-575, a quarterly tax-payment coupon or other IRS correspondence that contains this data. Requesting a verification letter (IRS 147C) from the IRS that identifies the LBN associated with your group s employer identification number. Reminder for Claims Submitted via Electronic Payment Statement (EPS): For electronic claim submissions, Taxpayer Identification Number is a required secondary identifier, with NPI being the primary identifier. At this time, the COSMOS and UNET platforms do not make any provider selection based on the NPI. If a claim is missing the TIN, then the system will use other data elements on the claim such as name, address, etc. to identify the provider. If a match is not made then the claim may be denied. UnitedHealthcare and its affiliates strongly encourage physicians and other health care professionals to submit their NPI information to us by one of the methods listed below. 1. Go to UnitedHealthcare s website at and select Practice/Facility Profile from the main menu. Log in with your User Identification and Password. Your Taxpayer Identification Number will allow you to access these screens online. Select Continue, then the View/Update NPI Information and tab to enter your NPI data online. 2. Call the United Voice Portal (UVP) at Select the Health Care Professional Services prompt. State Demographic Changes and your call will be directed to the Service Center to collect your NPI, corresponding NUCC Taxonomy Codes, and other NPI related information For all states, fax your NPI and related information to or The NPI Provider Data Fax Form and the Multiple NPI Submission Fax Form NPI can be found under Most Visited and National Provider Identifier at In addition, another helpful website is NPIRegistryPaginaeSearch. If you are a Medicaid provider, please pay special attention to the following section: Effective May 23, 2007, the Centers for Medicare and Medicaid Services implemented an initiative for all providers to obtain a National Provider Identifier (NPI) number. In order to continue caring for and receiving payment for Texas Medicaid members, providers must attest to their NPI data for each of their current Texas Provider Identifier (TPI) number(s). May 23, 2008, was the deadline. If you have not attested and you plan on continuing to see Medicaid members, please follow the steps below. Action Required from PCPs 1. In order to complete the online attestation process, please have the following items handy: a. The NPI assigned by the National Plan and Provider Enumeration System (NPPES). b. The provider s identifying taxonomy code(s). c. The tax identification or Social Security number associated with the NPI. d. The physical address, including Zip Go to the TMHP website ( 3. Click on Attest to an NPI. Access to the attestation page is granted through current administrative permission; only account administrators can attest online. 4. You must also register your NPI number with Evercare. (See # 1 under Reminder for Claims Submitted via Electronic Payment Statement (EPS). Please Remember It is the provider s responsibility to report their NPI to TMHP. If you do not attest to your appropriate TPI and NPI combinations, two things will happen: 1. If you are a PCP, your membership will be assigned to an attested PCP. 2. Claims will deny or reject or payment will be recouped. If you have any questions or need assistance regarding attesting or registering your NPI, please contact Evercare Provider Relations at Don t Forge. Don t Delay. Don t Put It off Another Day. Compliance with NPI registration is required.

3 Revised Quick Reference Guide and Evercare in Focus Newsletter Now Available Online Evercare s Quick Reference Guide was recently updated and mailed to your office in our quarterly provider mailing packet. The new format is cleaner and more user-friendly, and contains important information about Evercare and its policies and procedures. We also have it posted online to help your office find needed information quickly and easily. To access the online QRG, follow the navigation below on our website: Physicians + other HC Professionals Claims, Forms & Manuals Select Texas from the drop down box Select Reference Guides from the drop down box, Click Go Click on Quick Reference Guide for your service delivery area In addition, the latest provider newsletter, Evercare in Focus, also is online. To view a pdf of the newsletter, please follow the navigation below: Physicians Claims, Forms & Manuals Select Texas from the drop down box Select Physician Newsletters from the drop down box Click on Texas Physician Newsletter Note: Texas ICM Physician Newsletter is specific to Integrated Care Management providers in the Dallas/Fort Worth service delivery area.) Claims Denials? Review the Top Ten Reasons Are you experiencing denied claims? Check out the guide below to learn about the top 10 reasons why claims are denied: 1. Incorrect modifier. Providers file a claim(s) with missing modifier or incorrect modifier. This can be caused by a provider filing a claim electronically and putting a space in between the numbers or letters of the submitted modifier. In filing a CMS1500, providers leave off modifier(s) all together, or submit a partial modifier. 2. Incorrect place of service. Provider files the claim with the incorrect place of service for the services performed; i.e., member resides in an assisted living facility, place of service would be 12, but provider files with place of service 11, which is the home. 3. Incorrect diagnosis code. Provider files claim with the incorrect diagnosis or partial diagnosis code. 4. Provider cannot self refer. Specialist must include the name of the referring physician for the member. Providers input their name in provider referral area. Provider cannot be the attending and the referring physician. 5. Timely filing. Provider files claim past the initial 95 day filing limit, or the 120 day filing limit for adjusted claims. 6. Out of Network authorization required. Provider is out of the network and files claim without obtaining an authorization from the authorization department. 7. DME provider files for miscellaneous codes. Claims deny due to no coverage for miscellaneous codes. Provider should file a valid code for each service or supply. 8. No authorization. Provider is an in-network provider but fails to get an authorization for services, i.e., home health services, non-emergency transportation. 9. No notification. Provider performs a service or supplies durable medical equipment and does not notify the precertification department of the service. 10. Incorrect provider address/incorrect provider Tax ID. Provider moves or obtains a new Tax ID and does not notify Evercare of the new information. Evercare STAR+PLUS Member Complaints and Appeals May Affect Providers Evercare STAR+PLUS members have the right to voice their complaints about Evercare and/or their providers. Providers can play an important role in the complaint process either directly or indirectly. Why is this important to me as a provider? Because as the provider, it s important to understand the process and understand what the state of Texas requires. We encourage providers to know the process and educate Evercare STAR+PLUS members on the procedures for filing a complaint. Members can voice a complaint by calling Evercare s Member Services Advocate at A complaint can be filed right away or within a few days. There is no time limit to filing a complaint with Evercare. Evercare will send the member a letter telling them what we did about the complaint 30 days after the letter was received. STAR+PLUS members can also appeal decisions made about their healthcare services. STAR+PLUS members can even ask for an expedited appeal if they need an answer right away. Evercare is required to make a decision quickly based on the member s health status when taking the time for a standard appeal could jeopardize the member s life or health. STAR+PLUS members also can ask for a State Fair Hearing. This is important to a provider because according to the Health and Human Services Commission s Uniform Managed Care Manual, providers may be involved in a member s right to receive a State Fair Hearing. STAR+PLUS Member s Request for a State Fair Hearing If the STAR+PLUS member disagrees with the health plan s decision, the member has the right to ask for a fair hearing. The member may appoint, in writing, a representative. A provider may be a member s representative. The member or member representative must ask for the fair hearing within 90 days of the date on the health plan s letter. If the member does not ask for the fair hearing within 90 days, the member may lose his/her right to a fair hearing. To request a fair hearing, the member or member representative contacts the health plan either in writing or by telephone: 9702 Bissonnet, Suite 2200W Houston, TX The STAR+PLUS member has the right to continue any service he/she is now receiving until the final hearing decision if the member requests the fair hearing within 10 days from receipt of the hearing notice from the health plan. If a fair hearing is not requested within ten days from receipt of the hearing notice, the services being appealed will be discontinued. STAR+PLUS members do not have a right to a Fair Hearing if Medicaid does not cover the service the Provider requested. If the member asks for a fair hearing, the member will get a packet of information letting the member know the date, time and location of the hearing. Most fair hearings are held by telephone and the member or the member s representative may tell why he/she asked for the service. HHSC will give the member a final decision within 90 days from the date the member asked for the hearing. 4 5

4 Texas Health Steps: A Successful and Cost-Effective Public Health Tool Texas Health Steps (THSteps) medical checkups are an opportunity for a Medicaid certified child or adolescent to receive a comprehensive medical checkup. In accordance with THSteps policy, all components of the medical checkup must be completed for the provider to submit a claim. Providers must not refer a child receiving a THSteps checkup to an outside source for laboratory tests, immunizations, or other checkup components. Extenuating circumstances for either the provider or the recipient may impact the ability of a provider to complete a checkup. The following paragraphs present situations that may occur when a complete medical checkup cannot be accomplished, and the appropriate follow-up for the situation. A child may not cooperate with the provider for a specific component such as hearing or developmental screening which requires the child s participation. The provider must document the attempt to complete the component in the child s medical record. The provider may then submit a claim for payment for a medical checkup, and the child should be brought back for a follow-up visit to complete the pending specific component at the first available opportunity. If a child is ill during a checkup visit and an immunization cannot be completed, the provider should document the reason for not completing the immunization in the child s medical record. The child must be scheduled for a follow-up visit. There may be occasions when the child s illness interferes with a significant number of the components of the medical checkup, such as developmental testing, hearing and vision, or immunizations. In this situation, it is the provider s discretion whether to complete the checkup or bill for the visit as an acute-care visit and reschedule the child for a medical checkup. If the parent refuses a specific component such as an immunization or a laboratory test, the provider must provide the parent with information concerning the reason for the component. The medical record must document the education provided and the parent s refusal in the child s record. The visit may be billed as a complete checkup since the provider completed all the components for which consent was given. If the parent leaves the clinical setting before completing all the components, the provider should attempt to contact the parent, caretaker, or client to provide education concerning the reason for the component, and request that the parent return for a follow-up visit to complete the checkup. The medical record should contain documentation of the provider education and the attempt to reschedule. The visit may be billed as a complete checkup since the provider completed all the components to the best of his or her ability. If a significant number of components were not completed, then the provider may consider rescheduling the checkup and billing an appropriate acute care for those components that were completed. If a checkup component was not completed at a previous THSteps medical checkup and the child presents for another THSteps medical checkup, the provider should attempt to complete all components recommended for the child s current age. This includes bringing the child up-to-date for components that were not completed at an earlier age if the procedure is still appropriate for the child s age. There may be an occasion when the provider does not have adequate supplies. If a provider routinely has a problem with supply shortages, contact the regional THSteps provider relations staff for assistance. Contact information for the THSteps, Immunizations staff, and Tuberculosis regional staff can be found in the 2006 Texas Medicaid Provider Procedures Manual, Appendix A. For laboratory supplies providers may call , ext For more information, visit the TMHP Web site at Dental Checkups When a client is eligible for a Texas Health Steps (THSteps) dental checkup, a message is present on the Medicaid Identification Form (H3087) under the client s name. If the client or caregiver believes the client is due for a dental checkup and a message is not present, the provider may contact TMHP through the TMHP website at or AIS at to verify that the client is due for a dental checkup. Clients may receive an initial THSteps dental checkup at 12 months of age and at 6-month intervals thereafter, through 20 years of age. Clients younger than 12 months of age are not eligible for routine dental examinations; however, they may be referred when a medical checkup identifies the medical necessity for dental services. All THSteps clients from birth through 20 years of age can be seen by the dentist at any time for emergency dental services for trauma, early childhood caries (ECCs), or any other appropriate dental or therapeutic procedure. Clients from birth through 20 years of age may self-refer for dental services. The individual providing the medical checkup (if not the medical home provider) must ask the parents whether the client has a physician or primary care medical home provider where the client usually receives medical care. If the client s medical home is providing THSteps checkups, it is in the client s and family s best interest for providers to encourage the continuation of that relationship. If the family has a medical home but prefers to have their checkup done by another provider, then the rendering provider should send a copy of the THSteps medical checkup records to the primary care medical home provider. If the medical checkup provider is unable to offer a medical home to the client, the medical checkup provider must enter into written agreements with providers who are willing to offer medical homes. Oral Evaluation and Fluoride Varnish Initiative The Oral Evaluation and Fluoride Varnish initiative is a new program that will allow THSteps Program clients who are six months through 35 months of age to receive these services during medical checkups. Effective for dates of service on or after September 1, 2008, procedure code may be reimbursed for inter mediate oral examination and varnish application during a medical checkup. THSteps Program medical providers must complete training and be certified to provide the intermediate oral evaluations and fluoride varnish application before procedure code can be paid. Procedure code must be billed with diagnosis code V202 and the U5 modifier. THSteps physicians must bill procedure code S on the same day and by the same provider as procedure code S-99381, S-99382, S-99391, or S in an office setting. Federally Qualified Health Centers (FQHC) providers attending the training will be certified at the facility level. FQHC providers billing under THSteps must follow the standard claim submission process. Procedure code S will be an informational detail for FQHCs, following the standard encounter claims process. There will be no additional reimbursement for this procedure code. On August 1, 2008, the Department of State Health Services (DSHS) began training and certifying currently enrolled THSteps Program medical providers. For more information about training, contact Dr. Linda Altenhoff at linda.altenhoff@dshs.state.tx.us or , ext. 3001; or Dr. Dianne Forbes at dianne.forbes@dshs.state.tx.us or , ext Certification as an oral evaluation and fluoride varnish provider will be added to the advanced search criteria through the online provider lookup on the TMHP website at This change will enable users to find a physician who is certified to provide this oral evaluation and fluoride varnish treatment. For additional THSteps program and billing information, refer to the 2008 Texas Medicaid Provider Procedures Manual, Section 43, Texas Health Steps. Updates to the manual can be accessed at the TMHP website at under Medicaid Bulletins or call the TMHP Contact Center at

5 Documentation and Coding Training Offered to Medicare Physicians In the past few years, the Centers for Medicare and Medicaid Services (CMS) have begun to make greater use of ICD-9 codes as a means to assess severity of illness. Just as CMS uses Diagnosis Related Groups to reimburse hospitals, CMS groups diagnoses in order to the create Hierarchical Condition Categories scores used to fund Medicare Advantage plans. Thus, accurate documentation and ICD-9 coding are essential in order to ensure that each plan has the funds to provide the care each member needs. For instance, a member who has uncomplicated diabetes (ICD ) may need little more than a quarterly office visit and basic labs. Another member who has diabetes with peripheral neuropathy and Charcot joints (ICD and ) and diabetic nephropathy (ICD and ) may need periodic orthopedic care and procedures, follow-up by a nephrologist, and quarterly ambulatory care visits. To ensure that Evercare can continue to provide all the services that its members need, we look to our primary care providers to submit bills using diagnostic codes that are accurate, specific and comprehensive. To help our network physicians achieve high quality knowledge of ICD-9 coding, our sister company, Ingenix, offers a free coding training class to physicians and their office staff. The training is primarily for Medicare physicians as the material pertains to Medicare applications. Physicians can take advantage of this training by contacting the following representatives: Notify Network Management with Changes To ensure provider directory accuracy, please remember to notify United Healthcare and its subsidiaries, (i.e. Evercare ) if you have recently encountered changes to your office location, billing address, telephone number, Tax ID, closed your business, retired or changed your entity name. Adhering to the following procedure will ensure that your provider information is accurate and updated for all of the UnitedHealthcare Products. Providers must notify Evercare in writing on business letterhead or on the Evercare Provider Change Form. To obtain a Provider Change Form from our website, please follow these directions: Log on to Click on Physicians and Other Healthcare Professionals Click on Step 2 Physicians Forms Click Go Click on Request for address and tax ID number change form. Houston Service Delivery Area Porcia Davis Market Consultant Austin Service Delivery Area Jeffrey Roberts Manager, Market Consultants TX-OK-NM Nueces Service Delivery Area Charles Jones Market Consultant Dallas Service Delivery Area Nelda Bourquardez or Charles Jones Market Consultant Nelda Charles Changes can then be faxed to the following numbers according to provider type. Physicians and Facilities All other providers United Health Network Fax: Note: Corrected number Evercare of Texas Fax: Submit Reconsideration Form and Appeals Form Changes to New Address Effective December 1, 2008, Evercare s Reconsideration Form and Appeals Form should be mailed to a new address. You should have received updated forms in the Evercare December mailing. New Address: Evercare Appeal Request Form Evercare Reconsideration Request Form P.O. Box P.O. Box Salt Lake City, UT Salt Lake City, UT For more information, or to receive additional forms, contact your Senior Network Account Manager. The forms are also posted on, Physician Claims, Forms and Manuals. Verifying Eligibility Helps with Claims Payments Verifying Evercare STAR+PLUS membership is an important provider responsibility. It could affect whether or not you get paid for seeing Evercare members. Completing the following steps prior to seeing an Evercare member also will help with claims payments. When a patient identifies him/herself as an Evercare STAR+PLUS member, providers should verify eligibility through one or more of the following steps: 1. Ask for the member s Medicaid Identification (Form 3087) and their Evercare STAR+PLUS identification card. 2. Call the Automated Eligibility Line at Visit Evercare s online system at 4. Call the TMHP s Automated Inquiry System (AIS) at Call TexMedNet (TMHP s EDI Helpdesk) at If the patient is not eligible for medical assistance or certain benefits, the patient is treated as a private-pay patient. Failure to accurately identify a member can result in delays in processing claims, inaccurate claims payments and possibly no provider reimbursement if the patient is not a STAR+PLUS member. For additional questions, contact your provider relations representative at Evercare Wants to Hear from You! Our health-care providers play a key role in our commitment to improve the health and well-being of the members we serve. The first step in improving provider satisfaction is to ask the question: How are we doing? We value what you think and would like your feedback. Please take a moment to complete our Provider Satisfaction Survey by going to the following link: If you have any questions, you may reach us at Thank you for taking the time to help us improve our services. 8 9

6 Sign Up for Electronic Payments and Statements (EPS) Are you currently receiving Evercare claims payment and statements in paper format? If so, we encourage you to save time and money with EPS. EPS is an electronic feature that allows providers to get reimbursed electronically, rather than receiving a physical reimbursement check. The service is available to providers at no cost and helps streamline and simplify the payment process for Evercare and Secure Horizons** claims, as well as claims submitted for UnitedHealthcare members. Key benefits: Claims payments conveniently transferred directly into the checking account you designate. Less staff time spent on manual processing and claims reconciliation. Provider Remittance Advice (PRA) details each claims payment and is received online. Eligibility All network and non-network providers are eligible to enroll in EPS. Hospitals Laboratories Physicians Long-term services and support providers Other health-care professionals Product types EPS is available for the following product platforms: Commercial UnitedHealthcare products Medicare (not available in the Nueces service delivery area) Medicaid STAR+PLUS *Note: All health plan payments commercial, Medicaid STAR+PLUS and Medicare payments are bundled together into one convenient deposit. Claims are available to view online, print or save electronically. You Spoke and We Listened Sign up today. Here s how: To register online for this feature, follow these easy steps: 1. Log on to 2. Choose Claims and Payments. 3. Choose Electronic Payments and Statements. 4. If you already have a user ID and password, enter these in the spaces. If you do not have a user ID and password, choose Click Here and enter your provider information. 5. After your registration is complete, you will receive an confirmation. 6. You will begin to receive payments electronically in 7 to 10 business days. Or by fax: 1. Contact the EPS Help Desk at to request a registration form. 2. Fax the completed enrollment form to After the registration process is complete, a senior national account manager will contact you to discuss and ensure your satisfaction with this service. While this is not mandatory, we do encourage you to take advantage of the service as it is sure to create efficiencies within your office by reducing the time your staff spends on manual processing and claim payment reconciliation. If we can help with this transition, or if you have additional questions, please do not hesitate to contact the EPS Help Desk at UHC-FAST ( ), Option 5. **Not available for Nueces service delivery area. Evercare s authorization process just got better. Effective January 1, 2009, Evercare changed the authorization process for select long-term services and support providers. With this effective date, Evercare is now issuing yearly (12 month) authorizations for the following services: Adult Day Care (DAHS) Personal Assistance Services Private duty nursing (ongoing) Assisted Living/Residential Care/Adult Foster Care Ongoing supplies and DME DME rentals for one year Home delivered meals For existing Evercare members, authorizations will be issued for the entire service year. If the member is obtaining services on January 1, the authorization will run through December. If the service is starting at another point in the year, the authorization will begin at the start point and run through the end of the year. Authorizations continued on page 11 Evercare Assists Providers in Expediting Care for Children of Migrant Farm Workers Evercare of Texas strives to meet the unique needs of all of our members and endeavors to support our providers in reaching this goal. The Frew vs. Hawkins Corrective Action Order for Managed Care filed 04/27/2007 mandates Texas Medicaid Managed Care contractors and their providers must allow special provisions for accelerating services to children of migrant farm workers. Evercare policies have been developed to identify children of migrant farm workers enrolled in our plan, to accelerate and monitor the services they receive, and to report this data to the Health and Human Services Commission (HHSC). Due to the frequent transition of these members in and out of Medicaid service plan areas, efforts are focused on identifying member needs and implementing a service plan which supports the migratory patterns of these members. Historical data indicates that many of the children of migrant farm workers obtain delayed, limited or fragmented medical and dental care. These children experience difficulty with access to care. Their caregivers often do not understand their medical needs. Language barriers are sometimes present which results in inadequate care coordination. These children also have specific increased risk factors for health problems. Evercare identifies a child of a migrant farm worker and reports that child to HHSC. At that point, service coordination is expedited. For example, the member s Service Coordinator may work with the PCP or other service providers to arrange for expedited THSteps visits, assistance with scheduling a comprehensive assessment within 30 days of enrollment with Evercare, or coordinate a referral for specialists or ancillary services. Providers are encouraged to seek assistance from Evercare, if needed, as these members often transition in and out of their designated PCP enrollment lists. Providers may contact Evercare at and ask for the member s Service Coordinator for assistance in care coordination and help finding community resources. Providers may contact their Senior Network Account Manager directly if they encounter difficulties in expediting referrals to specialists or other providers. Providers may also access the following Migrant Clinician s Network website for resources on locations of Migrant Health Centers, patterns of migrant migration, common migrant health problems, migrant educational materials, and other additional resources: For more information, contact the Migrant Clinician s Network at Authorizations continued from page 10 HHSC has designated a Frew Advisory Committee to develop and endorse initiatives to promote access to care for children enrolled in Medicaid. During the February 2008 meeting, the committee endorsed an initiative called the Migrant Health Proposal Plan. This plan provides insight as to where these children live, an increased understanding of their needs and an improved communication and coordination of care with these families. Evercare will continue to provide education and resources for PCPs and ancillary providers as additional plans and information become available related to the needs of children of migrant farm workers. Children of migrant farm workers have an increased need for prompt medical care and detailed care coordination with follow-up. An active partnership between providers and Evercare will allow these members to experience an improved level of health-care services without interrupting the family s lifestyle. Please contact your Evercare Senior Network Account Manager if you have additional questions about these members. Upon receipt of the notification report from Evercare, it is imperative that providers review the report and reconcile it against their records. If a member under your care does not appear on the notification list, then services for that member have not been authorized in Evercare s care management system. Without this authorization, your claims cannot be paid. If you identify a member(s) that is missing from your notification roster, please immediately notify Evercare by calling or faxing a list of the members to It also should be noted that preauthorization is a condition of reimbursement. It is not a guarantee of payment. It is the responsibility of each provider to verify the member s eligibility monthly prior to rendering services. This step is important because Medicaid members can lose their eligibility monthly and they can change HMOs monthly. Questions or concerns about the new process can be directed to your provider relations representative. Additional questions can be directed to our provider relations department by calling We appreciate your willingness to partner with Evercare to streamline operations