El Paso First Quarterly Provider Meeting

1. El Paso First Quarterly Provider Meeting Wednesday November 11, 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 Lluvia Acuna – Migrant Outreach Coordinator Sonia Lopez – Claims Director Corina Diaz – Complaint and Appeals Specialist

3. EL Paso First Health Plans, Inc. WE ARE MOVING! – DECEMBER 18, 2009! Our new address is: 1145 Westmoreland Drive El Paso, TX  79925-5615 Please note: Paper Claim submissions will continue to go to: El Paso First Health Plans - Claims P.O. Box 971370 El Paso, X 79997-1370 Our General Correspondence address will not change. P.O. Box 971100 El Paso, TX  79997-1100

4. NEW LOCATION After the move all Complaints and Appeals will be sent to the new address.  Until that time, please send complaints and appeals to our current address to the attention of the Complaints and Appeals Specialist, as stated in your provider manual. We look forward to welcoming you at our new home!

5. Health Services Department Jim Voiland Health Services Director

6. Alberto N. Hawkins Settlement Update: • Time frame for response on authorizations changed to: • 7 day wait period  for requested information (previous 10 day)

7. Phototherapy Changes (In-Home) • Phototherapy changes for in home use – for  low-risk newborns which are defined as 35 wk gestation at birth (changed from 38 wks gestation) without co morbidity. • New total serum bilirubin levels. All requests must include: • THSteps-CCP Prior Authorization Request Form (page B-108 in the Tx Medicaid manual) • El Paso First Health Plans prior authorization request. Reminder – medium and high risk newborns – phototherapy is not a covered benefit for home use. Providers MUST submit documentation to support medical necessity (10/09/09 through 10/30/09) *****Attention All Medicaid Providers***** Effective for dates of service on or after November 1, 2009, benefit criteria for phototherapy devices will change for Texas Medicaid. Details of these changes are available on the TMHP website at www.tmhp.com for more information, call the TMHP Contact Center at 1-800-925-9126.

8. THSteps Updates Michelle Anguiano THSteps Coordinator Provider Relations Department

9. Periodicity Schedule Effective September 1, 2009

10. ASQ and PEDS Screening Tools • These screening tools will become mandatory in 2011. • If purchased and used now providers will receive an additional reimbursement. • Through August 31, 2011, providers may choose to use a standardized screening tool that is not listed in the Required Screening Ages and Tools table to complete the requirements of a medical checkup visit; however, providers may not submit a claim for a tool that is not listed in the following table. • Links for these tools are available at • http://www.epfirst.com/ProvidersEPSTD.html

11. Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Changehttp://www.tmhp.com/txtlstvw.aspx?LstID=b48ca997-4760-4d81-9401-5f92a493dd5d

12. Mental Health Screening Tools • Should be used at these ages: • 0-2 years, 3-9 years, 10-12 years, and 13-20 years • Can be found at • http://www.epfirst.com/ProvidersEPSTD.htmlunderTHSteps Mental Health Screening Tools • El Paso First’s Behavioral Unit can assist you by locating mental health and social services for your patients. • Contact the Behavioral Unit at 915-532-3778 ext 1500

13. OEFV Updates • Oral Evaluation and Fluoride Varnish Program and the First Dental Home Initiative trainings at EPCC Nov 5 and 6. • OEFV upcoming webinar: November 18, 2009. To register please go to: http://www.dshs.state.tx.us/dental/OEFV_Training.shtm

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

15. Member Services Department Edgar Martinez Member Services Director

16. Texas Health Steps Exams El Paso First Premier Plan (Medicaid) • $15 Welcome packet with OTC medications. • Preventive Dental Services for pregnant members over 21 years of age. • Eyeglasses valued up to $125 • Free Transportation for medical appointments. • Additional nutritional counseling services for members under 21 years of age. • Additional Behavioral Health services. 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

17. El Paso First CHIP Plan (CHIP) • $15 Welcome packet with OTC medications. • Preventive Dental Services for pregnant members under 19 years of age. • Additional 25% discount toward the purchase of lenses and frames • Additional 20% discount toward the purchase of disposable contact lenses. • Free Transportation for medical appointments. • Additional nutritional counseling services for members under 19 years of age. Page 1

18. El Paso First CHIP Perinatal Plan (CHIP Perinatal) • $15 Welcome packet with OTC medications. • Free Transportation for medical appointments. Page 1

19. 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. (915) 532-3778 or 1-877-532-3778

20. 3087 Form (Managed Care Medicaid) – Texas Health Steps Exams

21. 3087 Form (Traditional Medicaid) – Texas Health Steps Exams

22. STAR Provider Roster That Includes When Texas Heath Steps Medical Exams Are Due

23. Texas Health Steps Exams El Paso First provides: • 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.

24. Texas Health Steps • A child’s check up must be done no later than 90 days after his or her birthday.

25. Texas Health Steps • A child’s check up must be done no later than 90 days after his or her birthday.

26. 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?

27. 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

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

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

30. Compliance Department Rocio Chavez - Compliance Director Corina Diaz – Complaints and Appeals Specialist

31. How to Complain? All complaints must be in writing and mailed attention to Complaint and Appeals. What should be included in your complaint? Note: Adverse Determination complaints or appeals should be addressed attention Health Services Department.

32. What is a Complaint? • Acknowledgement • Resolution • What is a level 1 Appeal? • What is a level 2 Appeal? • Corrected Claims?

33. Claims Department Sonia Lopez Claims Director

34. Claims Guidelines • The provider must send electronic claims in a American National Standard Interchange (ANSI) 837P/837I format. • The provider must be sending CMS 1500 (Professional) claims. • Facility must be send UB04 (Hospital) claims. (Faxed copies will be accepted only if an original is on file for the DOS in inquiry.)

35. CMS 1500

36. CMS 1450 UBO4

37. Claim Verification • Clean Claim Edits • NPI Verification for Rendering and Referring Provider

38. Claim Notification Form

41. H1N1 Reimbursement • To Submit Vaccine: • Administration procedure code 90465, 90466, 90471, or 90472, 90470. • flu vaccine procedure code 90663, which will process as informational only.

42. Questions? El Paso First wishes you a joyful holiday season and a memorable new year 2010! Thank you for the great service you provide to our members!