El Paso First Health Plans SUD Provider Training Presentation Thursday August 19, 2010Slide 2
El Paso First Team Provider Relations Department Frank Dominguez – Director, Provider Relations and Contracting Michelle Anguiano – Provider Relations THSteps Coordinator Health Services Department Jim Voiland, MBA, MSN, RN – Health Services Director Janel Lujan, LMSW – Case Management Coordinator Claims Department Sonia Lopez – Claims DirectorSlide 3
Agenda Provider Relations Overview Healthx Fax System Substance Abuse Treatment Benefits Provider Care Unit (PCU) Claim Submission and Appeal Process Q/ASlide 4
Provider Relations Department Provider Relations OverviewSlide 5
Provider Relations and Contracting Department Liaison Between Network Providers, Health Plan and State Regulators (HHSC and TDI) Network Development (Recruitment) Provider Education Call 915-225-5463 Eligibility Verification Claims Information Authorization Information 24 hours a day 7 days a week Third Party Administrator Commercial Plan STAR/Premier Plan CHIP and CHIP Perinate Health Care Options Indigent ProgramSlide 6
Call 915-225-5463 Eligibility Verification Claims Information Authorization Information 24 hours a day 7 days a week STAR/Premier Plan, CHIP and CHIP PerinateSlide 7
EL Paso First Website El Paso First Website: www.epfirst.com Provider Relations Hotline: 915-532-3778 ext 1507 Access Provider Manual, Provider Directories and Forms Provider Newsletter Provider Forms (Authorization List, Demographic Update, and so forth.) Links Waste, Abuse and Fraud Educational Link TMHP Provider Procedures Manual CHIP, STAR, and CHIP Perinate Provider Manual CHIP Health Benefit Plan-Evidence of Coverage CHIP Perinatal Program for Unborn Children-Evidence of Coverage Call 915-225-5463 Eligibility Verification Claims Information Authorization Information 24 hours a day 7 days a week Third Party Administrator Commercial Plan STAR/Premier Plan CHIP and CHIP Perinate Health Care Options Indigent ProgramSlide 8
Provider Relations Department Contact Information:Slide 9
Questions? Much obliged to You!!!Slide 10
Health Services Department Substance Abuse Treatment BenefitsSlide 11
Pre-Authorization Overview Substance utilize treatment administrations Pre-approval prerequisites Behavioral wellbeing pre-affirmation shape Frequently made inquiries Case administration El Paso First emergency lineSlide 12
Substance Use Treatment Services Outpatient substance mishandle treatment administrations will get to be distinctly compelling September 1, 2010. evaluation walking detoxification guiding prescription helped treatment Residential advantages will get to be distinctly viable January 2011 (pending government endorsement). Private detoxification and treatmentSlide 13
Pre-Authorization Requirements Initial assessments don\'t require an approval Subsequent visits require an approval Behavioral Health Unit will prepare approvals inside 72 hoursSlide 14
Substance Use Benefits Available September 1, 2010 Assessment Billing code: H0001 Does not require earlier approval Outpatient singular advising Billing code: 9-H0004 Requires earlier approval Outpatient assemble directing Billing code: 9-H0005 Requires earlier approval Ambulatory (outpatient) detoxification Billing code: 1-H0014 Requires earlier approvalSlide 15
Substance Use Benefits Available September 1, 2010 Medication Assisted Therapy (MAT) MAT for opioid enslavement when utilizing methadone Billing code: 1-H0020 Requires earlier approval MAT for opioid habit when utilizing drugs other than methadone Billing code: 1-H2010 Requires earlier approval MAT for treatment of non-opioid compulsion Billing code: 1-H2010 Requires earlier approvalSlide 16
Substance Use Benefits Available January 1, 2011 Residential treatment Billing code: 1-H0011 Requires earlier approval Residential detoxification Billing code: 1-H0047, 1-H2036 (routine set of expenses) Requires earlier approvalSlide 17
Pre-Authorization RequirementsSlide 18
Pre-Certification Form For beginning solicitations, please give a brief story of the part\'s clinical presentation This data ought to be entered under " Evaluation of introductory treatment " For continuation demands, please incorporate an outline of why administrations need to proceed This data ought to be incorporated under " For continuation of treatment solicitations . . ."Slide 19
Pre-Certification FormSlide 20
Pre-Certification Form (pg. 2)Slide 21
Pre-Authorization: FAQ\'s What is the contrast between date of affirmation and date of system? Affirmation date – The date a part is admitted to an inpatient office Date of strategy – The date the supplier will lead the asked for CPT Code (i.e. 90806, 90847) Do I round out CPT Codes or Revenue Codes (Rev Codes)? CPT Codes are regular for most outpatient suppliers Revenue Codes are utilized by office suppliers (i.e. psychiatric clinics)Slide 22
Texas Health and Human Services Commission HHSC Reference: http://www.hhsc.state.tx.us/SubstanceAbuseBenefit.shtml#AnnouncementsSlide 23
Behavioral Health Case Management Team of medical attendants and social laborers help with the accompanying: Access and arrange administrations Integrate tend to people with a double finding Provide referrals to group assets for fundamental needs Referrals are acknowledged by the Case Management Coordinator at (915) 532-3778 or 1-877-532-3778 augmentation 1090Slide 24
El Paso First Crisis Line El Paso First individuals have entry to emergency mediation administrations 24 hours a day, 7 days a week El Paso First Premier individuals may call 1-877-377-6147 El Paso First CHIP individuals may call 1-877-377-6184Slide 25
Questions Janel Lujan, LMSW Case Management Coordinator (915) 532-3778 Extension: 1090Slide 26
Claims Department Claim SubmissionSlide 27
Verification of Authorization Claims Submission Remember to Bill with substantial Diagnosis Codes BOX 21 Remember to Point your Diagnosis code to the proper Service BOX 24E Submit Your Claim: Hand Written and Typed to El Paso First Health Plans - Claims P.O. Box 971370 El Paso, TX 79997-1370 El Paso First Web Portal at www.epfirst.com Electronic Billing by means of Clearinghouse To get to the EDI Form please go to our site at http://www.epfirst.com/frames/EDIPacket.pdfSlide 28
THIN Payer ID # P:\EDI Enrollment (Electronic Claims Submission)\THIN EPFirst EDISlide 29
Submission Process STEP (1) How can a supplier submit asserts electronically? The supplier may sign into the El Paso First Web Portal open through the El Paso First Website The supplier may submit bunch asserts through a clearinghouse STEP (2) What happens when the cases are gotten at the clearinghouse? At the point when cases touch base to the assigned clearinghouse the cases will be cleaned by the clearinghouse for HIPPA alters. Any cases that don\'t pass HIPPA alters will be dismisses by the clearinghouse in advance and the arrangement will never got the cases. The clearinghouse will send a reaction back to the supplier with any claim dismissals and blunder message. The supplier should rectify the cases and resubmit. All claims that pass the clearinghouse HIPPA alters will then be exchanged to the bearer (El Paso First Health Plans).Slide 30
Submission Process STEP (3, 4, 5) What happens when the cases are gotten at the bearer (El Paso First Health Plans)? El Paso First imports all group documents got from the clearinghouse every day. The El Paso First import framework will run the cases through framework alters. Any cases that don\'t pass the El Paso First framework alters will be dismisses and returned back with a reaction report (997 content document) back to the clearinghouse. The clearinghouse will then transmit the data back to the supplier for revisions. The supplier should rectify the claim and resubmit. All claims that pass the framework alters will import into the center cases handling framework.Slide 31
Submission Process STEP (6, 7, 8)What happens when the cases are transported in to the El Paso First claims handling framework? Every single imported claim will gone through auto settling on a daily premise. 80 percent of the cases will auto mediate and pay/prevent 20 percent from securing the cases will settle and Pend for manual auditSlide 32
CMS 1500Slide 33
CMS 1450 UBO4Slide 34
To Check Claim Status Providers may use the accompanying assets: Web entry account (www.epfirst.com) HealthX Fax System at 915-225-5463 (24 hours a day 7 days a week) Call the Provider Care Unit at 915-532-3778 augmentation 1504Slide 35
Claim/Appeal Filing Deadlines Claims must be gotten by El Paso First inside 95 days from DOS Corrected cases must be re-submitted inside 120 days from the R.A. (Settlement Advice) When an administration is charged to another protection asset, the documenting due date is 95 days from the date of the mien by the other protection bearer. It is emphatically suggested suppliers who submit paper claims keep a duplicate of the documentation they send. It is additionally prescribed paper cases be sent by confirmed mail with return receipt asked for & a point by point posting of the cases encased. .Slide 36
Provider Care Unit and how it functions Contact us at 915-532-3778 When calling you will achieve a Claims authority who will: Give guarantee status calls. Resolve or answer assert questions. Answer Electronic cases accommodation dismissals or inquiries. Help with cases debate. Rectified ClaimsSlide 37
Complaints and Appeals Complaint Process : Acknowledgment Resolution What is a level 1 Appeal What is a level 2 Appeal Please note you have the privilege to offer any mien of a claim through a formal interest. Composed req
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