2 Why you should submit electronic claims El Paso Health offers a Provider portal that allows you to view patients' eligibility and benefit information, verify claims, download reports, and submit primary or secondary professional and institutional claims at no cost. By submitting electronic claims, you can track your claims, cut down on paper, minimize any cash flow disruptions, and minimize turnaround time. Using the claim portal allows you to save money on claim forms, postage, and printing. Contact our Provider Relations Department at 915-532-3778, ext. 1507, if you need assistance obtaining access to our Provider portal. What is Payment Integrity? El Paso Health is proud to announce its new Payment Integrity solution. But what exactly is Payment Integrity, or PI? In a nutshell, the role of a good PI program is to increase the accuracy and automation of a health claim being paid correctly. It also ensures that the claim is paid by the responsible par ty for an eligible member; paid according to contractual terms and policy; not in duplicate or error; and free from fraud, waste, or abuse. A good PI program helps Providers like you avoid the associated risks of costly billing mistakes and keep more of the money you are entitled to for the valuable ser vices you provide to our members. Source: clarishealth.com/faq Pay for Quality (P4Q) HHSC implements a medical Pay-for-Quality (P4Q) program that creates incentives and disincentives for managed care organizations based on their performance on quality measures. This program holds up to 3% of our capitation rate at risk if certain benchmarks are not met. Below are the quality measures that are included. AT-RISK MEASURES STAR CHIP PPV – POTENTIALLY PREVENTABLE ED VISITS ED visits for conditions that are preventable or treatable with appropriate primary care (like URI, fever, etc.) X X PPA – POTENTIALLY PREVENTABLE ADMISSIONS Admissions for conditions that are considered preventable with appropriate primary care. X URI – APPROPRIATE TREATMENT FOR CHILDREN WITH UPPER RESPIRATORY INFECTION The percentage of visits for members 3 months of age and older who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. X CIS – CHILDHOOD IMMUNIZATION STATUS The percentage of children 2 years of age who had 4 DTaP, 3 IPV, 1 MMR, 3 HiB, 3 HepB, 1 VZV, 4 PCV, 1 HepA, 2 or 3 RV, and 2 flu vaccines by their second bir thday. X X PPC – TIMELY PRENATAL CARE The percentage of deliveries that received a prenatal visit within the first trimester or 45 days of enrollment with EPH. X PPC – TIMELY POSTPARTUM CARE The percentage of deliveries that received a postpar tum care visit within 7 to 84 days from date of delivery. X WCC – WEIGHT ASSESSMENT AND COUNSELING FOR NUTRITION AND PHYSICAL ACTIVITY BMI SUB-MEASURE The percentage of members 3 to 17 years of age who had an outpatient visit with a PCP or OB-GYN and who had proper documentation of BMI percentile in the medical record during the measurement year. X ADD – FOLLOW-UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION The percentage of children newly prescribed ADHD medication with at least 1 follow-up visit with a practitioner with prescribing authority within 30 days of prescription fill date. X resources
RkJQdWJsaXNoZXIy ODQ1MTY=