Provider Newsletter Fall • 2023 CHANGE SERVICE REQUESTED PO Box 971100 El Paso, TX 79997-1100 Nonprofit Org. U.S. Postage PAID Yakima, WA Permit No. 157 In a continued effort to assist our members with their Medicaid / CHIP re-enrollments, El Paso Health (EPH) is an HHSC Community Partner Program site. Several of our employees who are Case Assistance Navigators assist not only EPH members but anyone needing assistance with the Medicaid / CHIP application process. As we reached the end of the pandemic on May 11, 2023, several members were needing to renew their health benefits. We at EPH continue to work together with the community to reach out to enrollees of Medicaid / CHIP and remind them about the importance of submitting their renewals as well as reporting any changes. If you have EPH members inquiring about their coverage or renewals, feel free to direct them to call us at 915-532-3778 or visit our website at elpasohealth.com to make an appointment. We have appointment dates and times throughout the week dedicated to assisting with this process. Special services for children of traveling farmworkers El Paso Health has special Medicaid services for the children of traveling farmworkers. Services include assistance with scheduling upcoming Texas Health Steps exams as well as vision, mental health, and transportation benefits. If you have any questions or would like to receive more information about services for children of traveling farmworkers or would like to request an in-service for your staff, please contact our Outreach Coordinator at 915-532‑3778, ext. 1075. Working together for Medicaid re-enrollment
2 resources Provider Relations: Ready to serve you El Paso Health’s (EPH) Provider Relations (PR) team can help: ■ Educate providers and staff on administrative policies and procedures. ■ Communicate changes and updates that assist providers in the efficient administration of our plans. ■ Advocate on behalf of our Providers when working to resolve an issue. ■ Represent EPH networks in a knowledgeable and respectful way. ■ Assess the changing needs of a particular service area. ■ Manage changes to the demographic information of participating Providers. ■ And much more. GET IN TOUCH WITH YOUR PR REPRESENTATIVE. We are available Monday through Friday from 8 a.m. to 5 p.m. Call us at 915-532-3778 or email us at providerservicesdg@elpasohealth.com. We look forward to working with you! ABC Kids is now part of Children’s Clinic of El Paso It is with great pride and excitement that we announce that Patricia Azarcon Samonte, MD, at Children’s Clinic of El Paso, has acquired a new location. The dedicated staff are committed to the same quality pediatric care that they have been providing for over 27 years. Services include: ■Physical exams and immunizations. ■Routine pediatric care. ■Sick visits and basic lab screening. ■Circumcision and minor surgical procedures. ■Sports clearance exams. ■Breastfeeding support (with our own in-house certified lactation specialist). ■Nutrition counseling. ■Mental health diagnosis and support, including ADHD management and other behavioral concerns. ■Specialist referrals as necessary. ■Screening for hereditary genetic and metabolic conditions. ■Walk-in consultations. Patients can be taken care of at the previous ABC Kids location at 1700 N. Oregon, Suite 700, El Paso, TX 79902. Their phone number is 915-544-2225. Patients can also continue to be seen at the eastside location at 11544 Vista Del Sol Drive, El Paso, TX 79936. Their phone number is 915-592-2600. To schedule appointments or refer patients, please feel free to contact the office anytime or visit their website at drpatriciaazarcon.com. PROVIDER RELATIONS REPRESENTATIVES Claudia Aguilar 915-298-7198, ext. 1049 Shantee Aguilera 915-298-7198, ext. 1021 Jose Chavira 915-298-7198, Ext. 1167 Vianey Licon 915-298-7198, ext. 1244 PROVIDER RELATIONS COORDINATOR Liliana Jimenez 915-298-7198, ext. 1018 PROVIDER RELATIONS MANAGER Cynthia Moreno 915-298-7198, ext. 1044 DIRECTOR OF PROVIDER RELATIONS CONTRACTING & CREDENTIALING Erika Ozuna 915-298-7198, ext. 1119
3 IN CASE YOU MISSED IT! Update to PEMS for Clinical Laboratory Improvement Amendment (CLIA) In order to stay compliant with the CLIA requirements, a reminder was sent to all providers on April 7, 2023, for laboratory services utilizing CLIAs. Providers must submit their CLIA certifications through the Provider Enrollment and Management System (PEMS) and can bill only for services for which they have an appropriate CLIA certification on file. All providers that bill laboratory services must have CLIA certification for the procedure(s) being billed. If a provider bills for a procedure without appropriate CLIA certification, reimbursement will be denied. Providers must update their CLIA certifications in PEMS under the Licenses / Certifications / Accreditations link and may find more information about updating CLIA certifications in PEMS on the Licenses / Certifications / Accreditations page on tmhp.com. CLIA certification types These are the current CLIA certification types published by the Centers for Medicare & Medicaid Services (CMS): ■Certificate of Waiver. This certificate is issued to a laboratory to perform only waived tests. ■Certificate for Provider-Performed Microscopy Procedures (PPMP). This certificate is issued to a laboratory in which a physician, mid-level practitioner, or dentist performs no tests other than microscopy procedures. This certificate also permits the laboratory to perform waived tests. ■Certificate of Registration. This certificate is issued to a laboratory and enables it to conduct moderate- and highcomplexity laboratory testing until the laboratory is determined by survey to be compliant with CLIA regulations. ■Certificate of Compliance. This certificate is issued to a laboratory after an inspection finds the laboratory to be compliant with all applicable CLIA requirements. ■Certificate of Accreditation. This certificate is issued to a laboratory on the basis of the laboratory’s accreditation by an accreditation organization approved by CMS. stay informed Does your office have a step-by-step claim denial approach? Claim denials are a serious issue that affect your revenue cycle. What is your approach to identifying the root cause of denials? Analyzing data allows you to see where the problems are occurring. Whether the issue is in Patient Registration, Authorizations, Eligibility, or Coding / Billing Errors, claim denials can be very cumbersome. Regular analysis can help you resolve any potential issue before it becomes serious. Always stay on track with all health plan changes to ensure that your staff implements any system changes that affect claims. Top denials El Paso Health (EPH) has identified are: ■Benefit requires Utilization Management (UM). ■Claim is an exact duplicate claim to a previously submitted claim. ■Claim was not submitted in a timely manner (submission window exceeded). ■Authorization on claim not found. ■Authorization dates do not match claim. Remember, EPH has a dedicated team ready to assist you with your claim status inquiries. FOR MORE INFORMATION Call TMHP at 1-800-925-9126.
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 EPHP7472307-EPH-PR-Fall 2023 Provider Newsletter 2023 © Coffey Communications, Inc. All rights reserved. stay informed Noninvasive prenatal testing codes no longer require authorization El Paso Health (EPH) continues to improve health outcomes for our members. As of July 1, 2023, EPH has removed the prior authorization requirement for noninvasive prenatal testing (NIPT) for our in-network Providers. This means it is even easier for our Providers to provide high-quality care with less administrative burden. The CPT codes that no longer require prior authorization are the following for in-network Providers: ■CPT 81220 ■CPT 81243 ■CPT 81420 Please keep in mind that outof-network Providers continue to require prior authorization for the CPT codes listed. We encourage our Providers to use EPH in-network laboratory Providers to expedite these services. If you have any questions, please feel free to reach out to the Prior Authorization Department at 915-532-3778. Quality Improvement Initiatives: What you need to know HHSC holds El Paso Health (EPH) accountable to a variety of quality measures through varying initiatives. Based on 2021 data, EPH was asked to implement a variety of interventions to help drive performance on measures that were not performing to standard. Many of these initiatives include text messages and outreach to members to encourage them to schedule and keep their appointments with their Primary Care Provider and / or specialists. Some of the topics recently targeted include: ■Eye exams for members diagnosed with diabetes. ■Follow-up treatment after an Emergency Department visit for behavioral health. ■Encouraging members to know their Primary Care Provider. ■Educating pregnant members on the risk factors of having a baby with low birth weight. EPH takes steps to outreach and educate our members, but our Providers also play a key role in the success of our Quality Improvement Program! Everything from ensuring proper documentation during Well-Child visits to educating members on appropriate use of antibiotics contributes to meeting our goals. Things Providers can do to help ■Ensure adequate appointment accessibility. ■Make sure members have a follow-up appointment scheduled before they leave your office. ■Take steps to ensure adequate stock of vaccines. ■Make appropriate referrals to specialists as needed. ■Order appropriate labs and screenings based on specific risk factors. Please contact the Quality Improvement Department at 915-532-3778 if you have any questions. As always, we look forward to your continued cooperation on all our quality initiatives!
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