Provider Newsletter Fall • 2024 CHANGE SERVICE REQUESTED PO Box 971100 El Paso, TX 79997-1100 Nonprofit Org. U.S. Postage PAID Salem, OR Permit No. 86 How Member Services can help Providers Our Member Services Department is available Monday through Friday from 8 a.m. to 5 p.m. We are here to help you with any questions about your patients (El Paso Health members only) or our plans. Member Services can assist you with: ■Benefits and eligibility. ■Confirming Primary Care Provider change status. ■Claim status. ■Authorization status. ■Appeal status. ■Check tracers. ■COB (coordination of benefits) updates. ■Interpreter and sign language needs. ■Member transportation needs for appointments. Call us at 915-532-3778 or toll-free at 1-877-532-3778. We are here for you! Flu infection rates for children are the highest of any age group. About 20% to 30% of children get the flu every year. Yet, according to the Centers for Disease Control and Prevention, flu vaccination rates for children are 2.1% lower this season compared to the same time last season (53.9% compared to 56.0%). Preventing complications from the flu is very important, and this is where we need your help. Children should get the flu vaccine every year, starting at 6 months old. As a care Provider, you are your patients’ main source for the latest health information. Education from you can greatly impact a patient’s willingness to get vaccinated. To help you increase flu vaccine adherence, El Paso Health offers support and special initiatives. If you are interested in partnering with El Paso Health to host a flu drive, contact your Provider Representative at 915-532-3778. As a community, we can make a difference! We need your help!
Codes that require authorization Prior authorization is a process started by the ordering physician. Once a prior authorization is requested, El Paso Health will determine whether that treatment is medically necessary using medical criteria. It is a Provider’s responsibility to know which specific codes need prior authorization, and El Paso Health can help. You can use our Prior Authorization Tool and online catalog to check if prior authorization is required for your services. ■The Prior Authorization Catalog is a PDF list of CPT codes that you can search to see if prior authorization is needed. ■The Prior Authorization Tool is a search engine with which you can search for up to 4 CPT codes at a time to check if prior authorization is needed. For more information about our turnaround times, medical criteria, and forms, please visit our website at elpasohealth.com/providers/ medicaid-chip-prior-authorization or call us at 915-532-3778 or toll-free at 1-877-532-3778. Please note that prior authorization is subject to covered benefit review and is not a guarantee of payment. resources Tell your patient’s story with accurate and complete documentation For many reasons, documentation is required for any service given to a patient. First and foremost, missing or inaccurate documentation can cause a patient’s quality of care to suffer. Clinicians might make medical errors if they don’t have a complete picture of the patient’s health. This can lead to poorly planned care or incorrect treatments. Patients often have multiple clinicians. A patient’s care is especially affected when different members of their health-care team don’t communicate well. Without proper documentation, patients may receive conflicting treatment plans, disrupting their continuous care. In addition to patients and Providers, coders also rely on complete and accurate documentation. They need documentation in order to assign the correct CPT and ICD-10 codes and required modifiers for procedures. Coders also follow regulatory guidelines to ensure proper reimbursement. Compliance in medical coding is not just about following rules; it’s about protecting the integrity of patient data, optimizing billing processes, and ensuring providers are reimbursed accurately for their services. Clear and concise medical record documentation is critical for providing patients with quality care, ensuring accurate and timely payment for services, reducing malpractice risks, and helping health-care Providers plan and evaluate the patient’s treatment and maintain continuous care. 2
STAR+PLUS: Transition process for El Paso Health members Service plans Members’ existing service plans (SP) or individual service plans (ISP) will stay in place until El Paso Health service coordinators contact the member or their authorized representative to schedule an assessment. This assessment will determine if changes to the ISP are needed. Authorizations: In-network Providers For members who transition to El Paso Health’s STAR+PLUS plan, we will continue authorizations of current services in the same amount, duration, and scope for the shortest period of one of the following: 1. Up to 6 months after the member transfers to El Paso Health. 2. Until the El Paso Health service coordinators complete all required assessments, develop a new SP or ISP, and issue new authorizations. Authorizations: Out-ofnetwork (OON) Providers El Paso Health will continue authorizations of current services in the same amount, duration, and scope for the shortest period of one of the following: 1. Members can continue to see their current Providers, even if they are outside the health plan’s network. 2. If a member wants to stay with their current Provider who is OON, the managed care organization may seek to obtain a single-case agreement, OON authorization, or similar arrangement with the Provider to ensure continuity of care. 3. El Paso Health will continue to pay a member’s existing OON Provider for covered services for up to: ■ 90 days for acute care. ■ 6 months for long-term services and supports. ■ 9 months for a member who has been diagnosed with and is receiving treatment for a terminal illness. For OON Providers, please contact El Paso Health’s Contracting and Credentialing Department at 1-833-742-3127 or email contracting_dept@elpasohealth.com. Get ready for 2025 coding updates Claim denials can be a big problem. If not addressed quickly, frequent claim denials hurt your practice’s revenue and could possibly impact your ability to provide patient care. Even small coding errors can cause a claim to be denied. To prevent unnecessary claim denials, be sure to update your practice management software with the 2025 coding changes. ■ICD-10-CM/PCS codes for fiscal year 2025 will be effective on Oct. 1, 2024. ■Updates for CPT and HCPCS codes will be effective on Jan. 1, 2025. Review the new additions, deletions, and revisions to avoid claim denials due to incorrect diagnosis or procedure codes. stay informed 3
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 EPHP9422407 – EPH-PR-Provider Newsletter Fall 2024 2024 © Coffey Communications, Inc. All rights reserved. news Special services for children of traveling farmworkers El Paso Health offers special Medicaid services for children of traveling farmworkers. These services include help with scheduling Texas Health Steps exams, vision care, mental health services, and transportation benefits. If you have any questions or want more information about these services, or if you would like the program coordinator to provide training to your staff, please call the Outreach Coordinator at 915-532-3778, Ext. 1075. Alexandria (Allie) Melendez-Zaidi, MD, is a pediatric neurologist with wide-ranging clinical and research interests, including epilepsy, developmental disabilities, and neurogenetics. She serves on committees for several national organizations, like the American Epilepsy Society and the Pediatric Epilepsy Research Consortium. Dr. Melendez-Zaidi grew up in El Paso and is excited to move back home with her husband and four children. Dr. Melendez-Zaidi will lead the new Epilepsy Monitoring Unit in the soon-toopen intermediate care unit on the eighth floor of the hospital. She will work closely with Ziyad Makoshi, MD, who focuses on pediatric neurosurgery and epilepsy surgery, and join Rodolfo Fierro-Stevens, MD, who has been providing pediatric neurology care for children across the region. She will also collaborate with our behavioral health team to care for children with behavioral and mental disorders. The Brachial Plexus Clinic has been providing care to patients in the region for over two years. Patients with brachial plexus birth injuries and peripheral nerve disorders can receive treatment close to home, avoiding the need to travel hundreds of miles for surgery and care. Shawn Diamond, MD, a highly skilled plastic, hand, and microsurgeon, is the only doctor providing this complex service to patients between Phoenix and Houston. For more information and to learn more about the care provided to patients in West Texas, visit elpasochildrens.org. The neuroscience team at El Paso Children’s Hospital is expanding!
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