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Welcome ProvidersProvider Quarterly TrainingJanuary 21, 201680166EPF122215
Agenda Provider Relations: Federal Mandate Re-enrollment, NDCCrosswalk C.A.R.E.: THSteps Updates & Reminders Quality Improvement: Updates on 2014 Pay for Quality HEDISResults, 2016 Pay for Quality, and New PerformanceImprovement Projects Health Services: Case Management, Disease Management,Pharmacy, Non-Emergent Ambulance Transport Claims: Reminders Compliance: Complaints and Appeals Process, SpecialInvestigations Unit Member Services: Cultural Competency80166EPF122215
Provider Relations Updates:Federal Mandate Re-enrollment,NDC CrosswalkStacy ArrietaProvider Relations Representative80164EPF101315
Extended DeadlineThe Centers for Medicare and Medicaid Services (CMS) recentlyannounced that the previous March 24, 2016 deadline for Medicaidprovider re-enrollment is extended to Sept. 25, 2016. Though thisextension gives states additional time to ensure providers comply withPatient Protection and Affordable Care Act (PPACA) requirements, TexasMedicaid encourages all providers who have not yet submitted a reenrollment application to begin this process immediately to avoidpotential payment disruptions.Additional information will be announced in the coming weeks to assistproviders who are working on the re-enrollment process.80166EPF122215
Affordable Care Act Federal MandateRE-Enrollment All providers must revalidate their enrollment information everythree to five years. The frequency depends on the provider type. CMS requires that states complete the initial re-enrollment of allproviders by March 24, 2016. Which has now been extended toSeptember 25, 2016. Providers should submit their provider enrollment applicationnow. This will allow to resolve unexpected issues that may comeup during the enrollment process. All Providers must be enrolledby September 25, 2016. Any Medicaid providers enrolled prior to January 1, 2013, mustbe fully re-enrolled by the extended deadline of September 25,2016.801523EPF070815
Providers NOT – Re-enrolled bySeptember 25, 2016 Interruption in reimbursement for Medicaid servicesthe provider is not actively enrolled.Denial of claims for Medicaid services indicating thatthe provider is not actively enrolled.Removal of managed care organization (MCO) ordental maintenance organization (DMO) networks.* Providers must be enrolled in Texas Medicaid before they canbe contracted and credentialed by an MCO and DMO.80164EPF101315
Additional lease review the following helpful information on:Affordable Care Act FAQs - provides insight on questions regardingenrollment “e.g.” multiple TPIs, Online Provider Enrollment Portal (PEP),time frames, risk factors and much more Provider Types Required to Pay Application Fee – table displayswhich Medicaid and CSHCN Services Program provider types arerequired to pay the application fee upon initial enrollment, reenrollment, and enrollment of an additional practice location Provider Enrollment Electronic Signature Instructions Quick Tips to Avoid Common Provider Enrollment Deficiencies –suggestions for a clean application submission and avoid delays foradditional and missing information80164EPF101315
Additional Guidance Cont. TMHP Provider Re-enrollment page Provider Enrollment Representative:1-800-925-9126, Option 2 TMHP-CSHCN Services Program Contact Center:1-800-568-2413 Email at – PE-Email@tmhp.com80164EPF101315
2015-16 Texas Medicaid CHIP VDP Flu SeasonNDC to Procedure Crosswalk80166EPF122215
Contact InformationStacy ArrietaProvider Relations Representativesarrieta@epfirst.com915-532-3778 ext. 1059Provider Relations Department915-532-3778 ext. 1507801525EPF080715
THSteps Updates & RemindersMaritza Lopez, MPHTexas Health Steps Coordinator80166EPF122215
THSteps Updates Effective 1-1-16Effective January 1, 2016 only newborn screening specimen collectionkits that are thought to be defective may be returned.Title 25 of the Texas Administrative Code, Part 1, Chapter 37 (NewbornScreening Specimen Collection Kits), Subchapter D, Rule § 37.55 (b) (6)returned specimen collection kits reads as follows:– “(6) Returned specimen collection kits: if the purchaser believes a kit(s) isdefective, purchaser should immediately contact the department’slaboratory in Austin. Kit(s) which are verified to be defective by thedepartment can be returned for credit for future kit orders, as directed bythe department.”Credits toward future kit purchases will not be allowed for any otherreason.The DSHS Laboratory Services Section does not have the authority under§ 37.55 (b)(6) to provide refunds for any paid cards.80166EPF122215
THSteps Reminders Effective 11/1/15: Laboratory Screening– Anemia screening Removal of the mandatory screenings at ages 18 months andfemales at 12 years of age, leaving the mandatory screening at12 months of age only.– Human Immunodeficiency Virus (HIV) screening To add to the current risk based screening for ages 11 through20 years, the mandatory requirement to screen once betweenthe ages of 16 to 18 years of age, regardless of risk.– Dyslipidemia Screening (previously hyperlipidemiascreening) Mandatory screening requirements once for all clients betweenthe ages of 9-11 years of age and again for all clients betweenthe ages of 18-20 years of age, regardless of .shtm80166EPF122215
THSteps RemindersMental Health - Screening is required at each THStepscheckup and includes behavioral, social, and emotionaldevelopment.Must use one of the following validated, standardizedmental health screening tools recognized by THSteps isrequired once for all clients who are 12 through 18years of age: (Link to Bright Futures Materials & Toolspage to download the forms.)––––80166EPF122215Pediatric Symptom Checklist (PSC-35)Pediatric Symptom Checklist for Youth (Y-PSC)Patient Health Questionnaire (PHQ-9)Car, Relax, Alone, Forget, Family, and Trouble ps/providers.shtm
Contact InformationMaritza Lopez, MPHTexas Health Steps Coordinator915-298-7198 ext. 1071mlopez@epfirst.comAdriana CadenaC.A.R.E Unit Manager915-298-7198 ext. 1127acadena@epfirst.com801525EPF080715
Quality ImprovementUpdatesDon GillisDirector of Provider Relations andQuality Improvement80166EPF122215
Quality Improvement Updates 2014 Pay for Quality HEDIS Results 2016 Pay for Quality New Performance Improvement Projects80166EPF122215
Pay For Quality - ResultsCalendar Year 2014 STAR ResultsMeasureAbbreviation PopulationNameNumerRateW34UnitedHealthCare Community Plan20718287.92%W34El Paso First Health Plans, Inc41135486.13%W34Molina Healthcare of Texas, Inc.45338685.21%W34Driscoll Health Plan41134082.73%W34Community Health Choice28623281.12%W34Parkland Community Health Plan43234579.86%W34Texas Children's Health Plan41132779.56%W34Superior HealthPlan41132579.08%W34Seton Health Plan43234178.94%W3480166EPF122215DenomState Rate, Weighted*78.91%
Pay For Quality - ResultsCalendar Year 2014 STAR ResultsMeasureAbbreviation PopulationNameNumerRateAWCEl Paso First Health Plans, Inc41130975.18%AWCTexas Children's Health Plan41130774.70%AWCUnitedHealthCare Community Plan32123472.90%AWCCommunity Health Choice40329272.46%AWCDriscoll Health Plan41129772.26%AWCMolina Healthcare of Texas, Inc.45332070.64%AWCParkland Community Health Plan43230470.37%AWC80166EPF122215DenomState Rate, Weighted*68.70%
Pay For Quality - ResultsCalendar Year 2014 STAR ResultsMeasureAbbreviation PopulationNameDenomNumerRatePrenatalDriscoll Health Plan41138693.92%PrenatalEl Paso First Health Plans, Inc41138593.67%PrenatalCommunity Health Choice44641693.27%PrenatalSuperior 3%90.15%PrenatalState Rate, Weighted*MeasureAbbreviation teCook Children's Health Plan41129271.05%Community Health ChoiceRightCare from Scott & White HealthPlan44631570.63%45331469.62%Blue Cross Blue Shield of Texas43229868.98%Texas Children's Health Plan41128368.86%Driscoll Health Plan41128268.61%Amerigroup43029468.37%El Paso First Health Plans, Inc41128068.13%Aetna Better Health43229367.82%Seton Health Plan43228466.20%65.02%State Rate, Weighted*
Pay For Quality - ResultsCalendar Year 2014 CHIP NameDenomNumerRateW34El Paso First Health Plans, Inc.41135586.37%W34Community Health Choice30726485.99%W34Seton Health ll Health Plan41133280.78%W34Sendero Health Plans1038380.58%W34Community First Health Plans36629380.05%W34Parkland Community Health Plan*43234579.86%
Pay For Quality - ResultsCalendar Year 2014 CHIP ResultsMeasureAbbreviation PopulationNameAWCEl Paso First Health Plans, Inc.41130874.94%AWCCommunity Health Choice41829771.05%AWCSeton Health Plan43229668.52%AWCSendero Health Plans15510467.10%AWCDriscoll Health Plan41127266.18%AWCParkland Community Health Plan43228265.28%AWCTexas Children's Health PF122215Denominator Numerator RateState Rate, Weighted*61.33%
Pay For Quality 2016 No new changes from 2015 Measures include:MeasureSTARCHIPWell Child Visits, 3 – 6 year olds Adolescent Well Care Visits, 12 – 21 year olds Prenatal and Postpartum Care Potentially Preventable Admissions Potentially Preventable Readmissions Potentially Preventable ED Visits Potentially Preventable Complications 80166EPF122215
Performance Improvement Projects CHIP: Adolescent well-care visits (will continue in 2016) CHIP: Well-child visits in the 3rd, 4th, 5th and 6th years oflife (will end 12/31/15) STAR: Reduce ED utilization for URI and asthma 0-9 yrs.(will end 12/31/15) STAR: Reduce admissions for asthma by promotingasthma medication management (will continue in 2016) STAR & CHIP: Increase access to & utilization ofoutpatient care to reduce PPVs due to URI (NEW for2016)80166EPF122215
New 2016 PIP Interventions2016 Planned InterventionsBarrierLack of specific targeted contact for members whoutilized the ED for URI frequently.InterventionHome VisitsMembers do not know where they can go for after-hourscare or are not aware of the facilities closest to them.MCO is unable to contact members until after the fact –the MCO cannot know who utilized the ED for URI untilafter the visit has taken place and at this point, that visithas already had a negative impact on the PPV rate.Untimely contact of members who have used the ED forURI-having to rely on claims data alone.80166EPF122215Member MarketingHospital ED Lists
QuestionsDon GillisDirector of Provider Relations andQuality Improvementdgillis@epfirst.com915-298-7198 ext. 123180166EPF122215
Case ManagementCynthia Herrera, RN, BSNMedical Case Manager80166EPF122215
Case Management Goals Promote quality & cost-effective care Identify new problems before they becomeserious Help restore level of functioning Assist in navigating health care system80166EPF122215
Types of Case Management EPF offers the following types of CaseManagement:– Medical Case Management (including OOT)– Neonatal Intensive Care (NICU) CaseManagement– High-risk Obstetric Case Management– Catastrophic Case Management– Behavioral Health Case Management80166EPF122215
Service Coordination Early ChildhoodInterventions (ECI) Special HealthcareNeeds Program (SHCN) Social SecurityAdministration (SSI) WIC, Food Stamps,Community Food Banks80166EPF122215 Medical TransportationProgram (MTP) General AssistanceServices Housing & ShelterServices Support Groups
Case Management CM referral form on El Paso First rms/ Phone: (915) 532-3778 ext. 1500Fax: 915-298-786680166EPF122215
Disease ManagementGabriela MendozaDisease ManagementProgram Specialist80166EPF122215
Disease ManagementEl Paso First has a disease management programavailable for members who have uncontrolledchronic disease such as: Asthma Obesity Diabetes type 1 and 2 Heart Disease Over-utilizers of services (such as ER andpharmacy)80166EPF122215
Disease ManagementIn our disease management program our membersreceive: Health education Service coordination Health tip text messages Follow up calls Home visits Community resources80166EPF122215
Referral FormYou can refer your El PasoFirst patients to our diseasemanagement program byfilling out and faxing theprovider case managementreferral form on ourwebsite www.epfirst.comor by phone.Fax: 915-298-7866Phone: 915-532-3778, ext1175 or 107680166EPF122215
Disease Management Referral FormYou can find this form on our websitewww.epfirst.com under the provider tab, providerforms, then selecting the referral form under HealthServices Forms.80166EPF122215
Disease Management InterventionsAs part of our Performance Improvement Projects inaddition to collaborating with physicians the DM Teamwill conduct the following: Home visits will replace health education classes.– Home visits will help to assess member in their naturalenvironment.– Identify gaps in needed resources– Assist with service coordination and access to healthcare providers– Provide health education one-on-one or with the entirefamily.– Coordination of referrals to case management andother health resources80166EPF122215
Home Visit Identification Members can receive a home visit if:– A member is repeatedly utilizing the ER.– Has had either an ER visit or inpatient admit fordiabetic related conditions– Has had an ER visit or inpatient admit for anasthma exacerbation.– And other potentially preventable events (PPE)80166EPF122215
Asthma Medication Ratio (AMR)Continuing in our Performance Improvement Projectsfor 2016 (PIPs), our DM program will also focus onthe AMR.This is a ratio that is formulated to determine ifpatients with moderate to severe asthma are alsoprescribed controller medications in addition toinhalers.80166EPF122215
How Members Are Identified At least one ED visit with a principal diagnosis ofasthma. At least one acute inpatient encounter, with aprincipal diagnosis of asthma. At least 4 outpatient visits or observation visits, ondifferent dates of service, with any diagnosis ofasthma and at least two asthma medicationdispensing events. At least 4 medication dispensing events80166EPF122215
Asthma Medication RatioWhat are we doing with the AMR report?1. Sending a roster to providers to look intomembers on the list and make sure that they arebeing prescribed controller medications inaddition to fast relief medications. We need yourhelp.2. Calling the members to discuss asthmamanagement, medications, and set up anappointment for a home visit if needed.80166EPF122215
Contact UsCrystal Arrieta,Disease Management Program Coordinator915-532-3778, ext. 1175Gabriela Mendoza,Disease Management Program Specialist915-532-3778, ext. 1076Edna Lerma,Clinical Supervisor915-532-3778, ext. 107880166EPF122215
PharmacyPerla SaucedoPharmacy Technician80166EPF122215
SynagisMedicaid & CHIP Synagis season begins November 1, 2015 andterminates March 31, 2016. Providers who are eligible to request authorizationsinclude PCP’s, Pediatricians, PediatricPulmonologists, and Neonatologists. Provider will submit “Navitus Palivizumab (Synagis)Prior Authorization Form” directly to rmViewer.aspx?FormID 0bd350ad-d378-4d60-9cc4-d6e95b398a7380164EPF101315
Synagis (Medicaid & CHIP) Cont. Physician will fax Prior Authorization Form to eitherMaxor Specialty or Avella Specialty Pharmacy. Pharmacy will forward completed authorizationrequest form to Navitus for final approval. Pharmacy coordinates Synagis delivery with thephysician’s office. Physician administers Synagis and bills El Paso Firstfor the administration. (El Paso First does notrequire prior authorization for administration) Contact Navitus 24 hours a day, 7 days a week at1-877-908-6023.80164EPF101315
SynagisContact InformationMaxor Specialty Pharmacy Avella Specialty Pharmacy216 South Polk Street3016 Guadalupe St Ste. AAmarillo, TX 79101Austin, TX 78705Phone : 866-629-6779Phone : 877-470-7608Fax : 866-217-8034Fax : 877-480-1746El Paso First Health Services Department915-298-7198 x 1500Navitus1-877-908-602380164EPF101315
Flu VaccineMedicaid, CHIP, CHIP PERINATEPlan STAR Medicaid CHIP CHIP PerinateAges 0-18 18-Over80164EPF101315Location PCP orSpecialist(TVFCImmunizationsOnly) PCP orPharmacy *
FLU VACCINE Flu vaccine is available through pharmacy for STAR andCHIP Perinate members ages 18 and over. Vaccine is available through these tsonsWalgreensWal-MartK-MartTarget STAR and CHIP members 18 and under will continue tobe covered for Flu vaccine at PCP’s office For any questions regarding coverage, pharmacies andproviders can call 1-877-908-602380166EPF122215
TPA Updates: Flu Vaccine &Synagis80TPA162012016
Flu Vaccine PreferredAdministratorsPlan PreferredAdministratorsAges All AgesLocation PCP orSPECIALIST(flu shot isnot coveredat pharmacylocations)Preferred Administrators participating providersplease review Preventative Service Listing forappropriate Diagnosis and CPT codes atwww.preferredadmin.net80TPA162012016
SynagisPreferred Administrators Providers are required to send in the El Paso FirstPrior Authorization Form with clinical information toEl Paso First Utilization Management Departmentat 915-298-7866. The authorization form can be located on theEl Paso First res.pdfFor additional information concerning Synagisadministration for Preferred Administrators Members,please contact El Paso First Health Plans at 915-5323778.80TPA162012016
Medication ComplianceProviders may refer members to our casemanagement team when there is an issue withnon-compliance of medication. For example,member was prescribed a medication, but hasnot filled prescription, or has not takenmedication. Behavioral Case ManagementDisease Case ManagementOB Case ManagementMedical Case Management80166EPF122215
Contact UsPerla Saucedo,Health Services - Pharmacy Technician532.3778 ext. 1035For any questions regarding coverage,pharmacies and providers can call1-877-908-602380166EPF122215
Non–EmergentAmbulance TransportGilda Rodriguez, RNPrior Auth Nurse Coordinator80166EPF122215
EMERGENT TRANSPORTSEMERGENT TRANSPORTSDO NOTrequire prior authorization.Facility-to-facility transports are consideredemergencies if the required treatment for theemergency medical condition is not availableat the first facility80166EPF122215
Beginning April 1, 2016 El Paso First will require Medicaid-enrolled physicians,health-care providers, or other responsible party toobtain authorization before an ambulance is used totransport a client in non-emergent circumstances, inaccordance with Human Resources Code (HRC) §32.024(t). Other responsible parties include staff working with ahealth care service provider submitting priorauthorizations on behalf of the provider or facility. Aphysician order must accompany the prior authorizationrequest form. An ambulance provider may not request a priorauthorization for non-emergent ambulance transports.80166EPF122215
Non-Emergent TransportNon-emergency transport is defined as: ambulance transport provided for a Medicaid client to orfrom a scheduled medical appointment, to or from a licensed facility for treatment, or to the client’s home after discharge from a hospitalwhen the client has a medical condition such that the useof an ambulance is the only appropriate means oftransportation (i.e., alternate means of transportation aremedically contraindicated).All non-emergent ambulance transport services requireprior authorization along with documentation of medicalnecessity.80166EPF122215
Contact UsGilda Rodriguez, RNPrior Auth Coordinator532.3778 ext. 1016Edna Lerma, LPCHealth Services - Clinical Supervisor532.3778 ext. 1078Dolores Herrada, RN, CCMDirector of Health Services532.3778 ext. 100780166EPF122215
Claims RemindersJulie ZubiaClaims Processing Supervisor80166EPF122215
Claims Processing Timely Filling Deadline– 95 days from date of service Corrected Claim Deadline– 120 days from date of EOB– Use the comments section of the corrected claim formand be specific Web portal claim entry– List the authorization number in the header and in theservice line– Select correct ICD Code Type buttonICD-980166EPF122215ICD-10
Electronic Claims Claims are accepted from:– Availity– Trizetto Provider Solutions, LLC.(formerly Gateway EDI) Payer ID Numbers:»STAR Medicaid EPF02»El Paso First CHIP EPF03»Preferred Administrators UMC EPF10»Preferred Administrators EPCH EPF11»Healthcare Options EPF3780166EPF122215
ICD-10 Rejections & Denials Invalid ICD-10 codes will be rejected by theclearinghouse EPF will deny invalid ICD-10 codes80166EPF122215
ICD Indicator Reminder80166EPF122215
Contact InformationAdriana VillagranaClaims Manageravillagrana@epfirst.com915-532-3778 ext. 1097Provider Care Unit Extension Numbers: 1527 – Medicaid 1512 – CHIP 1509 – Preferred Administrators 1504 – HCO80166EPF122215
Complaints and Appeals ProcessDianna WattCompliance ManagerEPF-PR-FY14Q3 QPO 051514
Complaints & Appeals Process All Complaints and Appeals must be submitted in writing–– Appeals must be received within 120 days from the notice of the denialComplaints or Appeals must include detailed and supporting information:––––– All complaints/appeals are acknowledged no later than five (5) business daysAll complaints/appeals are resolved within thirty (30) calendar daysCorrected ClaimCopy of Remittance AdviceMedical recordsProof of Timely FilingProvide attested letter TPI/NPIComplaints must be addressed to:El Paso First Health Plans, Inc.Complaints and Appeals Unit1145 WestmorelandEl Paso, Texas 79925Note: Member’s must not be billed or balanced billedEPF-PR-FY14Q3 QPO 051514
Contact Information80166EPF122215
Special Investigations UnitComplianceAlma MerazSpecial Investigations Unit Claims AuditorEPF-PR-FY14Q3 QPO 051514
Monthly Random Medical Records Reviews Texas enacted bill 2292 to require all ManagedCare Organizations like El Paso First to establish aplan to prevent waste, fraud and abuse 5-7 providers are randomly selected on a monthlybasis– Edits, billing patterns, Health Plan request The process involves the review of paid claimsand if necessary a request for records A Business Records Affidavit is requiredEPF-PR-FY14Q3 QPO 051514
Medical Record SampleIf no recordsaresubmittedthey will berecouped800157EPF020215
Medical Records Reviews Findings El Paso First will send out a notification letter withthe findings at the end of the review– Will include detailed spreadsheets with claimrecoupment information You have the right to dispute the findings( within 30- days of receipt of the notice) The Recoupment process– Per the Office of the Inspector General’s directive El PasoFirst will recoup via claims adjustments80166EPF122215
Recoupment Letter Sample30 days to submit acorrected claim or anappeal from the date ofthe letter800157EPF020215
39 Week OB Reviews Random selection of 15 providers a month Records are requested and reviewed Ensures medical necessity of inductions and/orc-sections Reviews proper utilization of modifiers U1, U2and U3EPF-PR-FY14Q3 QPO 051514
OB Record Request Sample800157EPF020215
Member Services Verification Random selection of 60 members a month Courtesy phone calls to verify services wererendered as billed If not verified by member, records are requested The Provider will be notified of findingsEPF-PR-FY14Q3 QPO 051514
Contact InformationAlma MerazSpecial InvestigationsUnit Claims Auditor915-298-7198 ext. 1039ameraz@epfirst.comEPF-PR-FY14Q3 QPO 051514
Member Services Department:Cultural CompetencyEdgar MartinezDirector of Member Services80166EPF122215
Cultural Competency El Paso First places great emphasis on the wellness of ourMembers. A large part of quality healthcare delivery istreating the whole patient and not just the medicalcondition. Sensitivity to differing cultural influences, beliefs andbackgrounds, can improve a Provider‘s relationship withpatients and in the long run the health and wellness of thepatients themselves. We coordinate interpreter and translation services to meetthe Member‘s needs. El Paso First‘s Cultural Competencyand Linguistic Services Plan is available to its NetworkProviders upon request.80166EPF122215
Cultural Competency El Paso First‘s Cultural Competency and Linguistic Services Plan isavailable by contacting the El Paso First Member Services Department. For additional resources regarding cultural competency servicescontact:CLASinTexas: Resource for Adoption and Implementation ofCulturally and Linguistically Appropriate ServicesTexas Office of Minority Health and Health EquityCenter for Elimination of Disproportionality and DisparitiesCLASinTexas List-Serve Contact Information:CLASinTexas@hhsc.state.tx.us(512) 380-432580166EPF122215
Thank You!Edgar MartinezDirector of Member Services915-532-3778 ext. 1064Antonio MedinaEnrollment & Member Service Supervisor915-532-3778 ext. 1034Juanita RamirezMember Services & Enrollment Supervisor915-532-3778 ext. 106380166EPF122215
Thank You forAttending Providers!80166EPF122215
Blue Cross Blue Shield of Texas 432 298 68.98%. Postpartum . Texas Children's Health Plan 411 283 68.86%. Postpartum . Driscoll Health Plan 411 282 68.61%. Postpartum . Amerigroup 430 294 68.37%. Postpartum . El Paso First Health Plans, Inc 411 280 68.13%. Postpartum . Aetna Better Health 4
