CHANGE SERVICE REQUESTED PO Box 971100 El Paso, TX 79997-1100 Nonprofit Org. U.S. Postage PAID Salem, OR Permit No. 86 Provider Newsletter Spring • 2025 The Provider Relations Department offers a series of informative and engaging training sessions designed to support your ongoing professional development. These trainings provide valuable insights and tools that can enhance your practice and improve the quality of care you deliver. Training topics Topics offered include: ■Claims and Billing Best Practices. Stay informed on the latest claims submission procedures, billing practices, and error prevention techniques. ■Compliance and Regulatory Updates. Keep up-to-date with the latest regulations and requirements in health care. ■Customer Service Excellence. Improve patient and Provider relationships through effective communication and problem-solving strategies. ■Utilizing the Provider Portal. Learn how to maximize the features and benefits of our Provider portal to streamline your workflows. Why attend? Here are a few good reasons: ■Tailored content. Each session is designed with the needs of Providers in mind, ensuring relevant and practical takeaways. ■Experienced instructors. Our training sessions are led by knowledgeable Provider Relations team members who have realworld experience. Training opportunities for you ■Interactive learning. Participate in Q&A sessions and discussions to gain a deeper understanding of each topic. ■Enhanced resources. Leave with new tools and resources that you can implement directly into your practice. Find more training details at elpasohealth.com/prtraining. Don’t miss out on these valuable training opportunities—enhance your practice and strengthen your relationship with the Provider Relations Department! For more details or if you have any questions, feel free to reach out to our team at ProviderServicesDG@ elpasohealth.com. UPCOMING TRAININGS April—Behavioral Health / IDD Training May—STAR+PLUS Nursing Facility Training June—ASC Facilities / PT / ST / OT / Home Health / DME Training July—Medicare Advantage D-SNP Training Sign up to receive our Provider e-newsletter at elpasohealth.com/PR_E-Newsletter.asp.
2 news Disputing a payment or denial on a finalized claim If you disagree with a payment or denial on a finalized claim, we here at El Paso Health want to help you get the quickest possible resolution. Here are the steps you can follow, along with some helpful tips. Submitting a corrected claim. If your claim contains billing errors, submit a corrected claim using the appropriate resubmission code (6 or 7) and referencing the most recent claim number. You can find this number on your electronic remittance advice or in your Provider portal under claim details or reports. Providing the correct and most recent claim number ensures that your new submission appropriately replaces or corrects the previous one. Filing an appeal. If you continue to receive a denial or disagree with the payment after submitting a correction, you may initiate an appeal through our appeals and grievances process. A formal appeal requires a written letter, along with supporting documentation. Appeals can be submitted in person or via mail, fax, email, or phone. Two levels of appeal. If you disagree with the first-level resolution, you may submit a second-level appeal with new and additional supporting documentation to help our team reassess the dispute and work toward the best possible resolution. Further review. If, after the second-level appeal, you still have concerns about the outcome, we encourage you to reach out to our Call Center Representatives or your assigned Provider Relations Representative for further discussion and review. By following this process, we can ensure a more efficient resolution while minimizing duplication of efforts, ultimately leading to the best outcome for your office. Thank you for your partnership and commitment to providing quality care! Here we grow again! In October 2024, El Paso Children’s Hospital welcomed Xochitl CastilloRios, MD. Dr. Castillo-Rios is a pediatric nephrologist who, along with Ei Khin, MD, provides expert care to young patients with kidney problems. Muhammed Qureshi, MD, a seasoned pediatric cardiologist, joined the El Paso Children’s Hospital team in November 2024. He joins fellow pediatric cardiologists Jeffrey Schuster, MD, and Sudheer Gorla, MD. Together they will help grow the cardiology program to serve the El Paso community and beyond. In December 2024, after many years in private practice as the only pediatric neurologist in El Paso, Rodolfo FierroStevens, MD, joined the El Paso Children’s Hospital’s Multispecialty Center. He works closely with Ziyad Makoshi, MBBS, MSC, FRCSC, FAANS, and Alexandria (Allie) Melendez-Zaidi, MD, PhD, to care for pediatric neurology, epilepsy, and neurosurgery patients. El Paso Children’s Hospital hosted the Symposium on Endoscopic Surgery for Treatment of Craniosynostosis in November 2024. Neurosurgeons and oral and maxillofacial surgeons from around the world gathered to learn more about a minimally invasive approach to correcting craniosynostosis in young patients. The hospital also hosted the annual Southwest School Nurses Conference, in February of this year, where school nurses learned from our specialists how to care for students with special conditions. Stay tuned for more recruits and new services coming soon! Muhammed Qureshi, MD, Pediatric Cardiologist Xochitl Castillo-Rios, MD, Pediatric Nephrologist
3 resources Help us support members who must travel for care We understand and appreciate that coordinating care for our members can be challenging sometimes, especially when it requires out-of-town travel. To streamline this process and make sure our members receive the necessary support, we kindly ask that you send prior authorization (PA) requests as early as possible. Many of our members may qualify for assistance with transportation, lodging, and meals. These arrangements should be made well in advance to provide the best service possible for our members who are your patients. The first step in securing these services is to have an authorization approved for the member. Please be sure to send PA requests to the appropriate fax numbers listed here. Outpatient fax numbers ■Local: 915-298-7866 ■Toll-free: 1-844-298-7866 Inpatient fax numbers ■Local: 915-298-5278 ■Toll-free: 1-844-200-5278 Texas Health Steps medical checkups comply with federal and state requirements for a preventive checkup. Ageappropriate and risk-based laboratory testing is considered part of the medical checkup. The following table lists the laboratory tests that are required at each age. TEST / SCREENING AGE MEDICAL RECORD Anemia 12 months Documentation of H / H levels Blood lead 12 months and 24 months Documentation of blood lead levels Lead risk questionnaire Birth to 6 years Documentation of lead risk questionnaire or equivalent form of choice Newborn 2 weeks Documentation of results of second screening (obtained between 1 and 2 weeks of age at birth facility) Dyslipidemia 24 months to 20 years Risk-based test or decision not to complete specific test Dyslipidemia (mandatory) 9 years to 11 years and 18 years to 20 years Documentation must include dyslipidemia screening once at 9 through 11 years of age and once again at 18 through 20 years of age, regardless of risk. Diabetes 10 years to 20 years Risk-based test or decision not to complete specific test STD 11 years to 20 years Risk-based test or decision not to complete specific test HIV 11 years to 20 years Risk-based test or decision not to complete specific test HIV (mandatory) 16 years to 18 years Documentation must include HIV screening once at 16 through 18 years of age, regardless of risk. IF YOU HAVE QUESTIONS about the requirements for any Texas Health Steps checkups, please contact the Provider Relations Department at 915-532-3778. Texas Health Steps lab testing HealthX fax system ■Local: 915-225-5463 ■Toll-free: 1-866-283-2792 Thank you for your attention to this matter and for your dedication to providing quality care to our members. Your timely submissions help us ensure that all arrangements are made efficiently.
resources Provider Newsletter ABOUT YOUR HEALTH is published as a service for members of the EL PASO HEALTH Provider network. EL PASO HEALTH Executive Offices are located at 1145 Westmoreland Drive, El Paso, TX 79925, 915-532-3778 or 1-877-532-3778, elpasohealth.com. Information in ABOUT YOUR HEALTH comes from a wide range of medical experts. If you have any concerns or questions about specific content in this newsletter, call 1-877-532-3778. Models may be used in photos and illustrations. Member Services 1-877-532-3778 EPHP10642503 – EPH-PR-Spring 2025 Provider Newsletter 2025 © Coffey Communications, Inc. All rights reserved. How audits help prevent fraud, waste, and abuse El Paso Health’s Special Investigations Unit (SIU) conducts regular audits to help prevent fraud, waste, and abuse in health care. These audits ensure that Providers follow proper billing practices and that health-care funds are used correctly. Fraud, waste, and abuse in health care can lead to significant financial losses and affect patient care. By implementing strong internal controls and conducting thorough audits, El Paso Health’s SIU helps identify fraudulent activities and promote accountability among Providers. Regular audits also support compliance with state and federal regulations, reducing the risk of penalties and enhancing overall program integrity. El Paso Health partners with a thirdparty vendor that uses advanced data analytics and investigative techniques to identify anomalies in billing patterns and Provider behavior. Through proactive monitoring and collaboration with regulatory agencies, the SIU ensures that health-care services are delivered efficiently and ethically. Providers must promptly comply with medical record requests during audits or investigations. Complete documentation ensures claim legitimacy, accurate reimbursement, and regulatory compliance. Failure to provide records may result in payment denials, recoupments, or further review by agencies such as the Texas Office of Inspector General (OIG), Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services Office of Inspector General, or the Texas Office of the Attorney General. Noncompliance can lead to sanctions or legal action. Cooperation helps protect Providers and maintain health-care integrity. Always remember: If you suspect fraud or abuse, you can report it confidentially or even anonymously. Report to: ■El Paso Health fraud hotline: 1-866-356-8395 ■Texas OIG: 1-800-436-6184 or oig.hhs.texas.gov Interpreter services available for members Effective communication is essential in providing quality care. If you or your staff members encounter language barriers when communicating with El Paso Health members, we are here to help. El Paso Health offers in-person interpreter services, including sign language interpreters, for office visits. These services ensure that members receive the support they need for a clear and effective health-care experience. To arrange interpreter services, please contact our Member Services hotline: ■STAR Medicaid, CHIP, and CHIP Perinatal members: 1-877-532-3778 ■STAR+PLUS members: 1-833-742-3127 Scheduling requirements: ■Spoken-language interpreters— request at least 24 hours in advance. ■Sign language interpreters—request at least 48 hours in advance. We appreciate your commitment to serving El Paso Health members and ensuring accessible health care for all. Special services for children of traveling farmworkers El Paso Health has special Medicaid services for the children of traveling farmworkers. The services include assistance with scheduling their upcoming Texas Health Steps exams as well as vision, mental health, and transportation benefits for them. If you would like to receive more information about these services for children of traveling farmworkers or to arrange an in-service training for your staff, please call our Outreach Coordinator at 915-532‑3778, ext. 1075.
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