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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!