El Paso First Quarterly Provider Meeting

1. El Paso First Quarterly Provider Meeting Thursday, August 27, 2009

2. El Paso First Team Frank Dominguez – Director, Provider Relations and Contracting Irma Herrera – Supervisor, Provider Relations Cynthia Moreno – Provider Relations Representative Rene Duran – Provider Relations Representative Michelle Anguiano – Provider Relations THSteps Coordinator Eva Ortiz – Provider Relations Representative Evelyn Lopez– Contracting Representative Cindy Avalos – Contracting Representative Jim Voiland – Health Services Director Edgar Martinez– Member Services Director Monica Esparza – Member Services Supervisor Lluvia Acuna – Migrant Outreach Coordinator Sonia Lopez – Claims Director

3. El Paso First Contact Information Cindy Avalos Provider Relations Representative

4. El Paso First Departments Contact InformationMain number: 915-532-3778

5. Let us know that you are a Provider Let us know what Department you are trying to reach Let us know if you are calling to verify eligibility and for what program (STAR, CHIP, HCO or Preferred Administrators) In order to properly assist you before calling please have the following information ready: Page 1

6. Health Services Department Jim Voiland Health Services Director

7. TP-1 and TP-2 Forms • For initial therapy request the Provider must submit a request for “Initial Outpatient Therapy (Form TP-1)” that is signed and dated by the therapist and physician. • For extension of the therapy request the Provider must submit a “Request for Extension of Outpatient Therapy (Form TP-2)” that is signed and dated by the therapist and physician. • All physician and provider signatures on the TP-1 and TP-2 forms, physician orders, and other documentation must be current, unaltered, original, handwritten, and dated. Computerized or stamped signatures and dates are not accepted.

8. THSteps Updates Michelle Anguiano THSteps Coordinator Provider Relations Department

9. THSteps Policy Changes • On July 31, 2009 HHSC conducted the Medicaid Provider Responsibilities Workshop. • The following changes are effective September 1, 2009: • There are four new ages added to the periodicity schedule: • 3-5 days, 30 months, 7 and 9 years. • FQHCs and RHCs cannot submit a claims for a medical checkup encounter unless completed by the physician, advanced practice nurse, or physician’s assistant. The RN may assist in the completion, but the unclothed physical must be performed by the physician, APN or PA. • Lab specimens for glucose, hyperlipidemia, syphilis, and HIV related testing may go to the laboratory of the provider’s choice due to CLIA regulations regarding shipping of specimens.

10. THSteps Policy Changes cont. • Screening Ages Developmental Screening • 9 to 30 months providers need to use the ASQ or PEDS. • 3-4 years ASQ-SE or PEDS. • Reimbursement will be considered only if the tools above are completed. • Use of other tools will be allowed to meet the requirement for the next 2 years but will notbe reimbursed. At the end of the two year transition, checkups without the ASQ, • ASQ-SE or PEDS will notbe considered complete checkups.

11. Online Provider Education Requirements • Effective July 1, 2009 as per the Frew v. Hawkins’ Corrective Action Order:  Healthcare Provider Training, HHSC must recognize Medicaid enrolled health care providers who complete training on Frew and/or Texas Health Steps related topics.  • Health Plans will require their health care providers to take the training modules available through the DSHS Online Provider Education located on the DSHS website at http://www.txhealthsteps.com

12. Online Education Continued…… • All EPSDT Providers who have their own practice or belong to a group are required to complete the Online Modules. Additional information may be found on the website. You can also access this link at the El Paso First website by clicking at http://www.epfirst.com/ProvidersEPSTD.htmland selecting THSteps Online Provider Education. • Your STAR contract will not be amended, however, we are requesting for you to please attach the letter we mailed you to Section 4 of your El Paso First Provider Manual under Statutory Requirements on page 80.

13. Oral Evaluation and Fluoride Varnish Program Updates • Upcoming Webinars • For more information please log in to: • http://www.dshs.state.tx.us/dental/OEFV_Training.shtm

14. Resources to help you • Transportation • Provider Rosters • THSteps Members Due Only Lists • Birthday Reminder Postcard • Outbound calls

15. Contact Information • If you have any questions or concerns please contact me at: • E-mail: manguiano@epfirst.com • Phone: (915)298-7198 extension 1053.

16. Member Services Department Edgar Martinez Member Services Director

17. Texas Health Steps Exams How do you know when a member is due for a THSteps exam: • Their 3087 will state that they are due • Member’s due are listed on your Provider Roster • Call El Paso First to verify if the member is due for a THSteps exam at (915) 532-3778 or 1-877-532-3778

18. 3087 Form (Traditional Medicaid) – Texas Health Steps Exams

19. 3087 Form (Managed Care Medicaid) – Texas Health Steps Exams

20. STAR Provider Roster IncludesWhen THSteps Medical Exams Are Due

21. El Paso First Provides the following assistance for Texas Health Steps Exams • Assistance to the member to schedule a THSteps exam with their PCP. • Accelerated THSteps medical services for migrant members. • Transportation arrangements for members that are due a THSteps exam (Taxi rides). • Telephone reminder calls to the members that they are due a THSteps exam. • Mail a reminder “Happy Birthday” card to the member that is due a THSteps exam.

22. Texas Health Steps Happy Birthday Reminder Post Card • A child’s check up must be done no later than 90 daysafter his or her birthday.

23. El Paso First THSteps Incentive • A child’s check up must be done no later than 90 daysafter his or her birthday.

24. THSteps Missed Appointment Referrals • Missed Appointment Referral Service was created to help: • Reduce the number of missed appointments • Assist provider office staff with the issues missed appointments may create.

25. THSteps Missed Appointment Referral Form

27. THSteps Missed Appointment Referrals Outreach • Texas Health Steps Outreach and Informing Staff will: • Contact the referred recipient by phone call or home visit to provide appropriate assistance. • Will notify the provider of the results.

28. A seasonal farm worker is a person who works on farms, in fields, or as a food packer during certain times of the year. Seasonal farm workers move to different places to follow the crops. • El Paso First has special Medicaid services for children of seasonal farm workers: • We help schedule THSteps Medical Checkups appointments • Assist with accelerated THSteps medical services for migrant members • Vision Benefits • Mental Health Services • Night Clinics • Transportation Do you assist any Seasonal Farm Workers?

29. Estimado miembro, permítanos ayudarle: • El Plan Premier de El Paso First tiene servicios • especiales de Medicaid para niños de trabajadores • temporales del campo, por eso nos gustaría saber • lo siguiente: • ¿Es usted un trabajador temporal del campo? • Si No • ¿En la pizca de cebolla, chile, lechuga, tomate, • uvas, nueces, etc…? • Si No • ¿Empacando o procesando vegetales, frutas, • pescado, pollo, etc…? • Si No • ¿En lecherias, pesca, o matanza, etc…? • Si No • Si contesto SI a alguna de las preguntas, por • favor comuniquese con Lluvia Acuña, Coordinadora • Migrante, al (915) 532-3778. Le ayudaremos a • recibir servicios rápidos. ¡Gracias por su tiempo! Dear member, let us help you: El Paso First Premier Plan has special Medicaid services for the children of seasonal farm workers and we would like to know the following: • Are you a seasonal worker? Yes No • Picking onions, chile, lettuce, tomatoes, grapes, pecans, etc…? Yes No • Packing or processing vegetables, fruits, fish, chicken, etc…? Yes No • In dairies, fisheries, or slaughtering, etc…? Yes No If you answered YES to any of these questions, please contact Lluvia Acuña, Migrant Coordinator at (915) 532-3778. We will help you receive accelerated services. Thank you for your time! Questionnaire/ Cuestionario

30. Lluvia Acuña Migrant Outreach Coordinator (915) 532-3778 ext. 1075 Laura Caldelas Outreach Supervisor (915) 532-3778 ext. 1108 Contact Information

31. Member Services Department Questions? For more information please contact us at 915-532-3778 or visit our web site at www.epfirst.com

32. Claims Department Sonia Lopez Claims Director

34. WHO MAKES IT HAPPEN

35. Claims Department Leadership Contacts

36. Provider Care Unit (PCU) Have claims inquiries? Meet our top notch PCU team providing you assistance with your claims inquiries

37. PCU is here for you……..only a phone call away...... Contact us at 532-3778 When calling PCU a Claims Specialist will: • Give you claim status. • Resolve or answer claim questions. • Answer Electronic claims submission rejections or questions. • Assist with claims disputes.

38. Claim Formal Appeals You have the right to appeal any disposition of a claim through a formal appeal. Simply submit your formal appeal in writing to our Complaints and Appeal Department within 120 days from the date of your Remittance Advice (RA) to the following address: El Paso First Health Plans, Inc. Attn: Complaints and Appeals Department PO BOX 971370, El Paso, Texas 79997-1370

39. Understanding your Remittance Advice (RA) PROVIDER REMITTANCE ADVICE (RA)

40. Remittance Advice (RA) American Doctors P O BOX 123 El Paso, Tx 79999

41. Claim Number Assignment • Claim Number: 08017Y00136 • Claim Number Reversal : 08017Y00136R1 • Claim Number Adjustment: 08017Y00136A1 • Alpha Letters: (A thru Z) Manually Entered Claims • Alpha Letter: ( E ) Electronic Imported Claims • Numeric: ( 5) Portal Entered Claim Reversal/Adjustment Julian Year Julian Date Alpha Letter Claim No. 08 017 Y 00136 ( R ) or ( A )

42. EP First Top Denials

43. Questions? Thank you for your attendance!