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. Page 1
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. Page 1
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?