Provider Newsletter Fall • 2025 CHANGE SERVICE REQUESTED PO Box 971100 El Paso, TX 79997-1100 Nonprofit Org. U.S. Postage PAID Salem, OR Permit No. 86 By Patricia Rivera, RN I t’s that time again. School is back in session, the weather is getting cool, people are indoors, and the flu is ready to spread! As a Provider, you know that flu vaccines can prevent or reduce illness, reduce ER visits, and prevent missed work or school. The yearly vaccine may not match the circulating strains, but it can provide protection and hopefully reduce complications or hospitalizations. Informing your patients about the flu vaccine is critical so that they can have correct information from a credible source. WHO: Everyone 6 months and older should get a flu vaccine, especially those who are at higher risk of serious complications from influenza. WHAT: Vaccines are recommended for certain age groups. Types of vaccines are also available for certain age groups or medical conditions (nasal spray, recombinant, adjuvanted, and high-dose inactivated). WHEN: Get a flu vaccine every year. September and October are generally the months to get the vaccine. The flu vaccine may be considered for special populations at other times of the year. The importance of flu vaccines WHERE: Most doctors have already ordered their supply of flu vaccines, so it can be available at the office. Patients can also go to the local health department, community flu drives, pharmacies, etc. HOW: It takes about 2 weeks after vaccination for antibodies to develop in the body. While some people who get a flu vaccine may still get sick with influenza, flu vaccination has been shown in several studies to reduce the severity of illness. Reference: cdc.gov/flu/vaccines/vaccinations.html FOR MORE INFORMATION, PLEASE GO TO OUR WEBSITE. Under "Providers," click "Quality Improvement Program" and search for "Clinical Practice Guidelines" or "Quality Measure Tip Sheets."
2 news Substitute physicians and locum tenens WHAT YOU SHOULD KNOW When a doctor is out for a short time, another physician can step in to make sure patients continue receiving care. Medicaid allows this through 2 types of short-term arrangements: reciprocal and locum tenens. Knowing the difference helps keep billing clear and compliant. Per Texas Medicaid Provider Procedures Manual (TMPPM) Vol. 2, Section 9.2.3, both arrangements allow a substitute doctor to take over when the regular physician is away due to illness, vacation, training, or military service. A reciprocal arrangement is when another Provider covers for up to 14 days. This does not require a written agreement, and you will use modifier Q5 when billing. A locum tenens arrangement is used for longer absences: up to 90 days, or more if the doctor is on military duty. This type of arrangement must be in writing, and you will need to use modifier Q6. A few reminders ■The substitute doctor must be enrolled in Texas Medicaid and not on the HHSC exclusion list. ■Bill under the regular doctor’s NPI, and include Q5 or Q6 in Block 24D of the CMS 1500 form. ■Enter the substitute’s name and address in Block 19, not Block 33. ■For group practices, list the NPI of the doctor being substituted in Block 24J. Following these steps helps keep billing accurate and protects Medicaid integrity. For more details, see TMPPM Vol. 2, Section 9.2.3 or reach out to Provider Relations or Compliance. We are happy to help. El Paso Children’s Hospital: Here we grow again! El Paso Children’s Hospital (EPCH) opened its second urgent care center at 13647 Eastlake Blvd., Suite 204. It is open 365 days a year, from 9 a.m. to 9 p.m. Natalia BetancourtGuzman, MD, pediatric cardiologist, completed her fellowship in pediatric cardiology at the University of Minnesota. She joined the EPCH cardiology team in August and is scheduling new patients. Kristopher Hooten, MD, pediatric neurosurgeon, is joining the EPCH neuroscience team this September. He is fellowshiptrained in adult and pediatric neurosurgery and has specialized expertise in traumatic injuries to the brain and spinal cord. He was the first American Board of Pediatric Neurological Surgery-certified pediatric neurosurgeon in the U.S. military. German Lozano, MD, pediatric nephrologist, joined EPCH in May. He returned to El Paso after working at St. Christopher’s Hospital for Children in Philadelphia and Phoenix Children’s Hospital. Ethel Aguirre, MD, pediatric geneticist, recently completed her clinical genomics residency at the Mayo Clinic in Rochester, Minnesota. She is a graduate of the pediatric residency program at Texas Tech University Health Sciences Center, El Paso, and is excited to return to help serve children in our community. Marcella Woiczik, MD, and John Heflin, MD, pediatric orthopedic surgeons, will join EPCH in the fall. Dr. Woiczik is an expert at treating club feet and osteogenesis imperfecta and has a special interest in hip pathology and dysplasia. Dr. Heflin specializes in pediatric spine deformity, fracture care, and general pediatric orthopedics.
3 stay informed We recommend that Providers log in to your Provider Enrollment and Management System (PEMS) account monthly to ensure that your enrollment details are current, allowing you to complete necessary actions, such as revalidation and retroactive enrollment requests. Why log in to PEMS? ■Keep your information accurate: PEMS serves as the primary system for managing your enrollment. ■Receive critical notifications: PEMS will notify you of important actions that need to be taken, like deadlines on revalidations. ■Track enrollment status: PEMS gives you realtime access to the status of your revalidations or managing enrollment gaps. Revalidation due dates extended to Nov. 30, 2025 The Centers for Medicare & Medicaid Services (CMS) has extended the revalidation due dates for certain Providers to Nov. 30, 2025. If you have not yet completed your revalidation or received a notification to revalidate, this extension gives you more time to make sure your enrollment information is accurate and up-to-date. What does this extension mean for Providers? ■Providers who were previously required to revalidate by specific dates will now have until Nov. 30, 2025, to submit their revalidation documents. ■This extension provides a cushion for busy practices, giving you additional time to gather and submit necessary documentation and complete your revalidation process without worrying about penalties or payment interruptions. Stay safe in the heat Summer heat can be dangerous. One serious risk is heat exhaustion. This happens when your body gets too hot and can’t cool down. Signs of heat exhaustion ■Heavy sweating. ■Weakness or feeling dizzy. ■Headache. ■Nausea or vomiting. ■Fast heartbeat. ■Cold, pale, or damp skin. If you notice these signs, it’s important to act fast. How to prevent heat exhaustion ■Drink plenty of water, even if you’re not thirsty. ■Wear light, loose clothes. ■Take breaks in the shade or indoors. ■Avoid being outside during the hottest part of the day. ■Never leave kids or pets in cars. What to do if someone has heat exhaustion ■Move them to a cool place. ■Have them lie down and raise their legs. ■Give them cool water to drink. ■Put cool, wet cloths on their body. If they don’t feel better in 30 minutes or if they faint, throw up, or stop sweating— get medical help right away. Let’s all stay cool and safe this summer! Caring for the body and mind REMIND PATIENTS WHY YEARLY WELLNESS EXAMS MATTER Getting a wellness exam every year helps make sure patients' bodies are healthy and developing the way they should. At the appointment, the doctor might listen to their heart; check their height, weight, and blood pressure; and ask questions about how the patient feels, both physically and mentally. Some of these questions might be about mood, like how school is going or if the patient ever feels sad, worried, or stressed. These questions are not meant to be scary. They are very important, because mental health matters just as much as physical health. Encourage them to speak up Doctors ask these questions every year, because how a person feels on the inside can affect their body and their life. The doctor is there to help, not to judge. Keeping these questions in the yearly exam helps catch problems early, so patients can get help if they need it. It’s also a good time to learn new ways to stay healthy and happy. Everyone has hard days, and asking for help is a brave and smart thing to do. Wellness exams are a way to take care of the whole self—from head to toe, inside and out. FOR MORE INFORMATION on the revalidation due dates, visit tmhp.com/ news/2025-05-29-revalidation-due -dates-and-retroactive-enrollment -period-gap-closures-extended. Log in to PEMS to keep informed and up-to-date
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 EPHP11502507 - EPH-PR-Fall 2025 Provider Newsletter 2025 © Coffey Communications, Inc. All rights reserved. Avoid claim denials and reimbursement delays Submitting a clean claim the first time is one of the most effective ways to reduce administrative delays and ensure timely reimbursement. At El Paso Health, we are committed to supporting our Provider network with tools and education that promote successful claims processing. Below are some of the most common reasons for claim denials—and actionable tips to help your practice avoid them: 1. Missing or incomplete documentation What we’re seeing: Lack of medical records to support services billed, especially for high-cost procedures or durable medical equipment (DME). Tip: Always include supporting documentation with the initial claim when required (e.g., invoices for DME, notes for prolonged services, or justification for nonroutine care). 2. Inaccurate or incomplete coding What we’re seeing: Invalid CPT / HCPCS codes, incorrect modifiers, or mismatch between diagnosis and procedure. Tip: Stay current with annual code updates. Use the appropriate modifier to prevent bundling or rebundling issues. Confirm that diagnosis codes align with the services rendered. 3. Untimely filing What we’re seeing: Claims submitted beyond the allowable filing window. Tip: Monitor your internal timelines closely. Ensure that claims are submitted within the contracted time frame to avoid automatic denials. 4. Place of service (POS) mismatch What we’re seeing: Discrepancies between the POS listed on the claim and the Provider’s credentialed setting. Tip: Ensure that POS codes accurately reflect the location of service delivery and align with Provider enrollment records. 5. Lack of authorization or incorrect details What we’re seeing: Claims missing a required prior authorization or billing outside of authorized dates or services. Tip: Confirm that an approved authorization is on file before rendering services and ensure that claim details (CPT, units, dates) match the authorization exactly. Best practices for clean claim submissions ■Double-check member eligibility before service. ■Use clearinghouse edits and internal scrubbing tools to flag errors before submission. ■Regularly audit denied claims to identify trends or training opportunities for your billing team. ■Include itemized invoices when billing for equipment or high-cost drugs / biologics. 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 have any questions or would like to receive more information about these services for children of traveling farmworkers or would like for the program coordinator to provide an in-service to your staff, please call the Outreach Coordinator at 915-532‑3778, ext. 1075.
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