page 1 el paso first quarterly provider meeting wednesday march 18, 2009
TRANSCRIPT
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El Paso First Quarterly Provider Meeting
Wednesday March 18, 2009
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Program Agenda
Children with Special Needs Guest Speaker – Martha Payan
THSteps Oral Evaluation and Fluoride Varnish Certification and Hearing and Vision Training Date – Michelle Anguiano
Health Services preauthorization process updates – Jim Voiland
Provider Relations Updates – Rene DuranQuestion and Answer Session.
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Provider Relations
THSteps Oral Evaluation
and Fluoride Varnish Certifications
and Hearing and Vision Training Date
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Oral Evaluation and Fluoride Varnish in the Medical Home
Training and Certification for Medical Providers
EPSDT
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What providers need to know
•THSteps Pediatric Providers (Physicians, Physician Assistants, Advanced Practice Nurses) are trained and certified to provide a Dental Home for this population.
•Providers will conduct intermediate oral evaluation and application of fluoride varnish during a THSteps medical checkup.
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What providers need to know about on line training via webinar:
1. It is important for you to know that you will not receive a certificate via e-mail.
2. The DSHS will provide your contact information to TMHP so they can update the Master Provider Enrollment File.
3. Once completed the provider will receive an e-mail confirming file has been updated and an effective date to begin rendering this service.
4. Then, this file will be distributed to the Health Plans in an effort to update the provider’s record in their system so you can bill for this service.
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Billing•In order to bill for this application, the providers must submit proof of certification on this training to El Paso First’s Provider Relations Department by sending this documentation via fax to (915) 532-2877.
•This Department will forward this documentation to the appropriate contacts in order to process your claim.
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For more information
For complete guidelines and certification information please visit http://www.tmhp.com and search for July/August Texas Medicaid Bulletin No. 216, page 48.
You can find the links to obtaining a copy of the presentation and to order supplies to provide this service please go to http://www.dshs.state.tx.us/dental/default.shtm.
To access dates for webinars of in-person trainings please go to: http://www.dshs.state.tx.us/dental/OEFV_Training.shtm
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For further assistance
If you have any questions regarding this billing process, please contact the Provider Relations Department at 915-532-3778 ext 1507. Thank you for your collaboration in this
project.
Hearing and Vision Training• Goal: To provide attendees with Hearing and
Vision assessment and skills to screen for early detection and treatment.
• Date: April 13 thru April 17, 2009
• Time: 8:00 am to 5:00 pm – (Lunch on your own from 11:30 am to 12:30 pm)
• Location: Department of State Health Services 401 E. Franklin El Paso, Tx 79901
3rd Floor Conference Room
RSVP: Claudia Diaz via phone at 915-834-7724, fax at 915-834-RSVP: Claudia Diaz via phone at 915-834-7724, fax at 915-834-7802 or via e-mail at Claudia.Diaz @dshs.state.tx.us7802 or via e-mail at Claudia.Diaz @dshs.state.tx.us
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Health Services
Jim Voiland
Director of Health Services
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Pre Authorizations• Authorizations for OUTPATIENT/Scheduled
procedure requests, INPATIENT notifications and Clinical Information must be directed to Health Services Department if out of network.
• All Prior Authorizations must be submitted by Fax to :
• (915)298-7866 – Outpatient/Scheduled Procedures• (915)298-5278 – Inpatient Notifications• 72 hour turnaround time applies to all Prior
Authorization Requests
Pre Authorization List
Please Note:
All Requests must be received by fax.
Appropriate forms may be located at:
http://www.epfirst.com/Providers.html
NCB = Not Covered Benefit
STAR CHIPPREFADM
HCO SSI
X X X NCB XX X NCB X
X X
X X X X XX X X NCB XX X NCB NCB XX X X NCB X
X X X NCB X X XX X X X XX X NCB X
X X X NCB X
X X X X XX X X X XX X X X XX X X XX X X NCB XX X X NCB XX X X X X NCB X X X X XX X X NCB XX X X NCB X
X X
STAR and CHIP services or procedures that are not a covered benefit according to the Texas Medicaid Provider
298-7866
FAX NUMBER:
Procedures Manual are a non-covered benefit for El Paso First Members (Unless it is a Value Added Service)
Behavioral Health (Initial evaluation does not require pre-authorization)
X =PREAUTHORIZATION or NOTIFICATION
REQUIRED
NCB = NOT A COVERED BENEFIT
El Paso First appreciates the care you provide for our
members.
Please notify El Paso First AS SOON AS POSSIBLE to begin
the pre-authorization process.
72 Hour advance notice allows us to review the request for services and
respond in a timely manner.
X
X X
NCB
NCB
X X
X X
X
INPATIENT
FAX NUMBER:
298-5278
X
Pre-authorization is based on information provided to El Paso First at the time of request, and does not guarantee payment of benefits nor verify eligibility. Payment for services is subject to all terms, conditions, limitations and exclusions related to the member's eligibility and subsequent medical review. Regardless of pre-authorization
status, medical decisions concerning a course of treatment are solely between the physician and the patient.
Please FAX all Pre-certification for OUTPATIENT/ SCHEDULED PROCEDURE
requests, INPATIENT Notifications, and Clinical Information to our Intake Unit.
MEDICAID FEE SCHEDULE IS AVAILABLE ON LINE AT: www.tmhp.com/default.aspx
OUTPATIENT
Outpatient Procedures (excluding Outpatient Chemo, except for PREF ADM Members)
Out-of-Network / Non-Participating Facility, Provider, or Vendor
Transplants
PET ScansPodiatry ServicesDialysis Services
Chiropractic ServicesCT ScansDurable Medical Equipment (For STAR and CHIP: Over $300.00 line item allowable rate)
Transportation (Air Transport and Non-emergent Ambulance)
$ High Cost Medications Oral (Over $500.00)
$ High Cost Medications Injectable (Over $500.00)
Sleep StudiesSpecialist-to-Specialist ReferralsSynagisTherapy Services (OT, PT & ST - Except initial evaluation)
X
Non-Emergent Admission
Growth Hormones Hearing AidsHome Care
X NCB
XX X
Oral SurgeryOrthotics and Prosthetics (For STAR and CHIP: Over $200.00 line item allowable rate)
Note: All PREF ADM members under the age of 18 require prior authorization
Nutrition CounselingOB/GYN Ultrasounds (Requests greater than two)
Note: Member is allowed a maximum of two ultrasounds total without pre-auth regardless of location
PROCEDURES & SERVICES REQUIRINGPREAUTHORIZATION/NOTIFICATION
X
X
Note: All DME rentals exceeding 2 months require pre-authorization
Inpatient Admissions
Laser SurgeriesMRI/MRA
Note: El Paso First must be notified of all inpatient admissions within 24 hrs or next business day on all emergent admissions.
Elective Admissions
ALL SSI REQUIREMENTS
ARE THE SAME AS THOSE STATED IN
THE TEXAS MEDICAID PROVIDER.
PROCEDURES MANUAL.
Updates/Changes Notifications
Provider Relations
UPDATES AND CHANGES
Provider Relations needs to know:
• Changes in address locations
• Name Changes
• Billing company changes
• Phone and fax updates, etc.
Any changes we need in order to update our system and your records.
• Changes in address locations
• Name changes
• Billing company changes
• NPI/TPI updates
• Phone and fax updates, etc.
Any changes you consider we may Any changes you consider we may need in order to update our system need in order to update our system
and your records.and your records.
Provider Relations needs to know:
• Claims
• Authorizations
• Payments
Importance of notifying El Paso First
Not notifying El Paso First may affect:
Reporting changes to El Paso First
• Contact the Provider Relations Department or your Provider Relations Representative.
• Fax over letter notifying us of the changes.
• Assigned Representative will contact the provider once we have updated our system and their records.
Provider Relations- Ph. 532-3778 ext. 1507 Fax 532-2877
Utilizing El Paso First Web SiteUtilizing El Paso First’s Web Sitehttp://www.epfirst.com/
• Access to web portal sign in.
• Provider Forms (i.e.inpatient/outpatient pre-cert forms)
• Information on all programs under El Paso First.
• View provider directories for all programs.
• Upcoming News and Events.
• Provider Manual (STAR/CHIP/CHIP Perinatal)
• Provider Newsletter
El Paso First’s Newsletter
• Mailed out to providers once every Quarter.
• Newsletter located in El Paso First’s website.
• Updates/changes
• News/events
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Questions and Answers
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On behalf of El Paso First
Thank you for your attendance and all your hard work!