star provider roster that includes when texas heath steps
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Pertussis, Strep Throat testing & Resources
Michelle Anguiano
C.A.R.E. Unit Manager
Pertussis, Strep Throat testing & Resources
Michelle Anguiano
C.A.R.E. Unit Manager
Adult vaccination recommended
• Pregnant women and anyone else likely to come into contact with young babies are being urged to get booster shots to prevent whooping cough, even if they have been vaccinated in the past.
• Babies are most likely to die or be hospitalized when they get the highly contagious bacterial disease, which is named for the characteristic cough that accompanies it.
• The CDC recommends Tdap booster for adults aged 19-64 who have not received Tdap previously. Pregnant women should wait until after the 20th week of pregnancy or preferably in the third trimester. If not given during pregnancy, then the dose should be given as soon as possible after delivery.
Pertussis and Cocooning Handbook
• The purpose is to ask OB GYNs, Family Medicine Providers, Pediatricians and Hospital-based doctors to implement cocooning strategies in their practices.
• Cocooning strategies: Vaccinating adult and adolescent patients and family members with the Tdap vaccine to protect the infant they have contact with as well.
• Copies are available upon request or via our website (www.epfirst.com) under Texas Health Steps Resources.
Appropriate Pharyngitis (Strep Throat) Testing
• The Centers for Disease Control (CDC) encourages careful antibiotic use and avoiding antibiotic resistance by treating only proven group A strep. Most sore throats are caused by viral agents, with only about 15% of pharyngitis cases caused by group A strep.
• What Providers Can Do
• The CDC recommends promoting appropriate antibiotic use as part of your routine clinical practice. Some practice tips include:
* Explaining that unnecessary antibiotics can be harmful and viral infections cannot be cured by antibiotics.
* Encouraging active management of the illness and describing the expected normal time course of the illness.
* Creating an office environment to promote the reduction in antibiotic use.
ResourcesPediatrics
• www.healthychildren.org
Family Physicians
• http://www.aafp.org/online/en/home.html
OB GYNs
• http://www.acog.org/
All Specialties
• http://www.tmhp.com
Texas Health Steps Tools & Updates
Maritza LopezTHSteps Coordinator
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Hemoglobin & Newborn Screenings• Effective 12/1/11, a hemoglobin electrophoresis test is no longer required in addition to the
NBS or included as a separate test during the Texas Health Steps (THSteps) medical checkups at any age.
• Included in the newborn screening (NBS) required at birth and again at 1-2 weeks of age.
• A NBS should be obtained on all infants up to 12 months of age if not previously obtained or results are not available.
• Providers will be receiving new THSteps specimen submission forms. When medically necessary, Providers may obtain a hemoglobin electrophoresis test.
• The specimen may be sent to the DSHS laboratory (using the form G1B) or the client may be sent to a laboratory of the Provider’s choice. Providers must use their acute care provider number when ordering a medically necessary hemoglobin electrophoresis test.
• Bulletin 239: Newborn Examination - Procedure codes 99460, 99461, and 99463 should not be billed with modifier 52. The descriptions of these newborn exam codes reflect the completion of all the Texas Health Steps checkup components.
ImmTrac Registry• Free service• Stores child’s immunization information
electronically• One centralized system• Consent is during birth registration process OR
completion of consent form• For more information please log on to
http://www.dshs.state.tx.us/immunize/immtrac/default.shtm
TVFC Update• Available at no cost to Providers• As part of providing comprehensive care package to patients• Updated policy
– Children birth through 18 years of age who meet at least one of the following criteria are eligible to receive TVFC vaccine from any TVFC-enrolled Provider.
– Criteria: • Medicaid eligible• Uninsured• America Indian or Alaskan Native• Underinsured:“A child who has commercial health insurance, but coverage does not include vaccines; a child whose
insurance covers only selected vaccines (TVFC-eligible for non-covered vaccines only); or a child whose insurance caps vaccine coverage at a certain amount. Once that coverage amount is reached, that child is categorized as underinsured.”
• New TVFC Standardized Forms– Patient Eligibility Screening Record-C110– TVFC Patient Decision Screening Tree– Patient Referral Form for Vaccination from local Health Department or Public Health Clinics
For more information on TVFC please log on to:http://www.dshs.state.tx.us/immunize/tvfc/default.shtm
Happy Birthday Reminder Card
Please complete back portion with DOS, member ID#, Provider name/stamp.
*Effective September 1st: $25 gift card to Walmart or Cinemark*
Accelerated Services for Children of Migrant Farmworkers
• State initiative to provide a THSteps checkup and accelerated services to children of migrant farm workers due to the uniqueness of this population.
• Collaborating with the Migrant Outreach Coordinator to educate our providers about these services.
• If you have any patients from El Paso First that meet this criteria please refer them to Lluvia Acuña, Migrant Outreach Coordinator at 915-532-3778 ext 1075.
Migrant Postcard
– Maritza Lopez-THSteps Coordinator• E-mail: [email protected]
• Phone: (915)298-7198 extension 1071
– Lluvia Acuña-Migrant Outreach Coordinator• E-mail: [email protected]
• Phone: (915)298-7198 extension 1075
– Michelle Anguiano-C.A.R.E. Unit Manager• E-mail [email protected]
• Phone: (915) 298-7198 extension 1053
Contact Information
Resources for OB/GYN PROVIDERS
Stacy Arrieta
OB Provider Relations Representative
Pregnant Members Ob program
Baby showers Calendar
Forms
• S
FormsS
Contact Information
Stacy ArrietaProvider Relations Representative
298-7198 ext. 1059
Health Services Department
Janel Lujan
Health Services Director
Pre-Authorization • Prior authorization flyer identifies authorization
requirements
• Submit required documentation
– (i.e. Title XIX forms, TP1, TP2 forms)
• Submit supporting clinical information
– (i.e. evaluation, plan of care)
Pre-Authorization Form
• Submit complete and legible pre-certification form
• Enter applicable CPT Codes and ICD-9 Codes
• Complete the member’s identifying information
- Name - Date of birth - Identification number
Amendments
• When requesting an amendment, please include the following:– Original authorization number
– Clinical information to support the amendment
Notifications
Partial Approval • The Medical Director has approved
services with a modification from the original request.
• The provider receives a fax notifying him/her of the approval.
• Provider has the opportunity to request a peer to peer discussion.
Administrative Denial • Requested services were not
approved.
• Example:
– No clinical information is submitted within the requested time frame
– Service is not a covered benefit
• The provider receives a fax notifying him/her of the denial and a formal denial letter with appeal rights.
Communication
Health Services Extensions
• Medicaid x 1500
• CHIP x 1536
• Health Care Options x 1537
• Preferred Administrators x 1538
Sonia LopezClaims Director
ICD-10 Overview
Implementation Date
Project Approach
What does “WHO” mean?
ICD-10 Code Count Comparison
Transition Period
Day Submission Illustration
Inpatient Professional Service DOS After 10/1/2014
Inpatient Facility Services Discharge after 10/1/2014
Inpatient Facility Services Discharge before 10/1/2014
1.
Major Goals for ICD-10
Diagnosis Comparison Chart
Procedure Comparison Chart
Mapping Conversion
Structural Distinction of the Diagnosis Codes
ICD-10 Diagnosi Code StructureCategory Codes
ICD-10 Diagnosis Code StructureCategory Codes
ICD-10 Diagnosis Code StructureCategory Codes
Compare the Diagnosis Coding
ICD-10-CM Helpful Links
Sonia Lopez, BS, CPC
Director of Claims
(915) 532-3778 Ext: 1097
Provider Care Unit Extension Numbers:
• 1527 – Medicaid
• 1512 – CHIP
• 1509 – Preferred Administrators
• 1504 – HCO
Value Added Services for El Paso First Health Plans
Members
Edgar Martinez
Director of Member Services
El Paso First Premier - Medicaid Memberswill receive the following extra benefits:
• $25 movie gift card or $25 shopping gift card for Members age 20 and under that go to a Texas Health Steps exam.
• $15 Health First Packet of over-the-counter medications, such as Children’s Tylenol, digital thermometer, first aid kit, pedometer, school supply kit, and much more.
• Eyeglasses with a retail value up to $125. • $25 movie gift card or $25 shopping gift card for pregnant
Members that go to a prenatal visit and attend a prenatal class.
• Up to $295 of preventive dental services for members.• Up to $25 for any sport registration activity fee once every 12
months for all members.• Additional transportation services for medical appointments
and health education classes. • Additional nutritional counseling services for children age 20
and younger. • Additional behavioral health benefits.
El Paso First CHIP - CHIP Memberswill receive the following extra benefits:
• $25 movie gift card or $25 shopping gift card for pregnant Members that go to a prenatal visit and attend a prenatal class.
• $15 Health First Packet of over-the-counter medications, such as Children’s Tylenol, digital thermometer, first aid kit, pedometer, school supply kit, and much more.
• Up to $25 for any sport registration activity fee once every 12 months.
• 25% discount towards purchase of lenses and frames. • 20% discount towards purchase of disposable contact
lenses.• Up to $295 of preventive dental services for members. • Additional transportation services for medical
appointments and health education classes. • Additional nutritional counseling services for children
age 19 and younger.
El Paso First CHIP PerinatalCHIP Perinatal Members
will receive the following extra benefits:
• $15 Health First Packet of over-the-counter medications, such as prenatal vitamins, Children’s Tylenol, digital thermometer, first aid kit, pedometer, school supply kit, and much more.
• Additional transportation services for medical appointments and health education classes.
• $25 movie gift card or $25 shopping gift card for pregnant Members that go to a prenatal visit and attend a prenatal class where they get a diaper bag and a car seat.
Questions?
Thank you!