El Paso Health | About Your Health | Winter 2021

Utilization Management perspective El Paso Health (EPH) is continually enhancing the Utilization Management perspective for a more efficient and effective prior authorization process. EPH is committed to improving the process, not only for our Providers but to ensure timely access to treatment for our members. Over the last year, EPH has formulated a variety of new processes. ■ For example, a therapy request checklist will be introduced at the upcoming therapy provider webinar, allowing providers to utilize a checklist to ensure all documents and information are complete when submitting a prior authorization request. This will allow for the authorization process to be completed promptly and not be placed on hold for an additional information request. ■ EPH will also be implementing flexible options for physician orders so providers can meet the prior authorization request requirements with less difficulty. More good news includes improved technological capabilities, including the workflow engine (WFE). The WFE places prior authorizations in their designated queues where they will be reviewed based on priority and submission date. We continue to encourage all of our Providers to submit timely authorizations well in advance of the service being requested. Continuing to assess processes and solve Provider’s practical challenges will further foster a genuine collaboration between EPH, Providers, and members. We believe that quality service to our Providers through reduced administrative burdens will positively impact quality care for our members. Vianka Sanchez, MS, CCC-SLP T he Texas Health and Human Services (HHSC) contracts with an External Quality Review Organization (EQRO) to monitor all MCOs on appointment accessibility (i.e., how soon an appointment can be scheduled from the time of request). The 86th Legislative Session (SB 760), effective Sept. 1, 2019, mandates that Texas HHSC monitor MCO networks and analyze compliance with appointment standards. MCOs are required to pay liquidated damages if performance thresholds are not met on these studies. The EQRO implements these studies for each MCO using secret shopper calls. While this initiative was put on pause in the early stages of the COVID-19 pandemic, the EQRO has resumed implementation as of June 2020. The standards set by HHSC and the Texas Department of Insurance (TDI) for appointment accessibility are as follows: Appointment type Standard (calendar days from time of request) Emergency Services Upon member presentation Urgent Care Within 24 hours Routine Primary Care Within 14 days Specialty Routine Care Within 21 days Specialty Therapy (PT / OT / ST) Evaluations Within 21 days of signed referral Initial Outpatient Behavioral Health Within 14 days Referrals for Specialty Care Within 5 days Prenatal Care–Low Risk Pregnancy Within 14 days Prenatal Care–High Risk Pregnancy or New Member in 3rd Trimester Within 5 days Preventive Health–Adults (21 years and older) Within 90 days Preventive Health–Children (less than 6 months) Within 14 days Preventive Health–Children (6 months to 20 years) Within 60 days Please note that all Providers designated as PCPs are also required to be available to our members 24/7. If you have any questions on the requirements, please contact the Provider Relations Department at 915-532-3778 . Appointment accessibility statewide studies 3 resources