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Compliance Corner by wulinqing


									                                                                      Provider Newsletter Summer 2011

                                       Compliance Corner
                                   El Paso First and Provider Education

El Paso First Health Plans, Inc. (El Paso First) appreciates the care you, as Providers, offer our
Members. Routinely, we must make you aware of the federal and state government’s efforts to
reduce waste, abuse, and fraud in all government funded healthcare programs; this includes CHIP
and Star programs. El Paso First conducts most reviews prospectively during claims processing but
identification of other errors also happens retrospectively during medical records review. El Paso
First contracts with Allied Management Group – Special Investigations Unit (AMG-SIU) to conduct
retrospective medical records reviews and claims analysis to determine if there was an overpayment
of claims or indication of repetitive errors that might constitute waste, abuse or fraud.

El Paso First has a local Special Investigations Unit that works in conjunction with AMG in analyzing
these reviews and handles recoupment of overpayments as well as Provider Education. Once
AMG-SIU has finalized a Provider review, El Paso First receives a statistical sampling report that
identifies all errors found along with amount of overpayment per claim
reviewed. After analyzing the report, an individualized Provider education
letter will be prepared and mailed out via Certified Mail to your office.
This letter will offer you a summary of findings during the review with
statistical information that compares your practice with like Providers
(in the same specialty). If specific errors are identified, a clear
explanation and detailed educational references will be provided
explaining the coding errors. El Paso First offers face-to-face
explanation and review of your billing patterns or findings.
Please contact us with any questions or concerns.

El Paso First Health Plans, Inc.
Compliance (SIU)

Rocio Chavez                 Laura Wilson
Compliance Director          Special Investigations Claims Auditor

915.298.7198 ext. 1032       915.298.7198 ext. 1169
                                Medicaid Buy-in                                                                      Medicaid Buy-in Cont.
Program Lets Families ‘Buy-in’ to Medicaid to Help Insure Children with Disabilities

Even when resources are scarce, parents of kids with disabilities go to extraordinary      How to Apply for Medicaid Buy-in
lengths to be good providers. But sometimes, not even the hardest work and greatest
sacrifice can bridge the gap to affordable health insurance. For some of these Texas       If you think you may qualify for Medicaid Buy-in, call 2-1-1 and ask to have an
families, the Medicaid Buy-in for Children program may be able to help.                    application mailed to you. You also can apply at any Texas Health and Human
                                                                                           Services Commission benefits office. Call 2-1-1 to find one near you.
The program is for families who need health insurance for their children with
disabilities but make too much to qualify for regular Medicaid and too little to afford    The 2-1-1 service (as well as the alternative free number, 877-541-7905) is open
private insurance. It helps qualifying families who’ve fallen into this gap by letting     between 8 a.m. to 8 p.m. Central Time. When you call, pick a language, then pick
them make a monthly payment to “buy-in” to Medicaid.                                       option 2. You’ll need to pick “Medicaid” from among the options.

Medicaid Buy-in delivers serious health insurance value for kids. Some of the covered      If you’re deaf, hard of hearing, or speech impaired, you can call 7-1-1 or
services include: checkups, visits to doctors, clinics and hospitals, emergency care,      800-735-2989 to be connected to any number.
home care, medicines, glasses, mental health care, speech and occupational therapy
and general help with Medicaid services (case management).

To be eligible for the Buy-in program, a child must be single, 18 or younger, a Texas
resident, a U.S. citizen or legal resident and qualified under disability guidelines for
Supplemental Security Income (SSI).

The program’s monthly premiums are set up to be manageable, based on factors such
as income, size of the family, other insurance coverage through work and whether a
family is in another program called Medicaid Health Insurance Premium Payment (HIPP).

For Buy-in program participants who already have some health insurance from
their employer, Medicaid may even be able to cover services their work insurance
doesn’t. However, Medicaid Buy-in program will only pay for services available from a
Medicaid doctor. And program participants also must keep their insurance from work
if their employer covers half or more of the cost.

Some families have to pay part of the cost for their child’s doctor visits, hospital
stays, medicine, therapy, and other health services. Those out-of-pocket expenses
have an annual cap, though. When a family meets their annual limit, they often don’t
have to make additional monthly payments until their next benefit period.

Another possible option for folks who have some health insurance through their work
is the Medicaid Health Insurance Premium Payment Program (HIPP). When you apply
for Medicaid Buy-in for Children, the state will check to see if you qualify to have
HIPP pay your premium.
                          Member Services Corner                                                          Member Services Corner Cont.

The Your Texas Benefits Medicaid Card and                                             How am I supposed to use the Your Texas Benefits Medicaid card?
provider website frequently asked questions: Providers                                Use the new Your Texas Benefits Medicaid card to verify a patient’s Medicaid
                                                                                      eligibility just like you did with the paper Medicaid ID (Form 3087).
                                                                                      The card’s magnetic stripe has the client’s Medicaid ID number (PCN) and it can be
• The Texas Health and Human Services Commission is introducing a new system          read by most swipe-style card readers. The Your Texas Benefits Medicaid card is
  that uses digital technology to streamline the process of verifying a person’s      designed to work with standard magnetic card readers that are available at many
  Medicaid eligibility and accessing their Medicaid health history. The two main      electronics retailers or online. These readers interface with your computer through
  elements of the system are:                                                         a standard USB connection.
• The Your Texas Benefits Medicaid card, which replaces the Medicaid ID letter        A company called Emdeon is offering Medicaid providers an enhanced point-of-sale
  (Form 3087) clients have been getting in the mail every month.                      device that processes Medicaid eligibility verifications as well as credit card transactions.
• An online website where Medicaid providers can get up-to-date information on        As with more standard card reading options, Medicaid providers that choose this device
  a patient’s eligibility and history of services and treatments paid by Medicaid.    are responsible for the cost. For more information, visit Click on
                                                                                      “Contact. Us.”

What information will be on the card?

• The design of the new card conforms to the standards of the Workgroup for           What if I don’t have a swipe-style card reader?

  Electronic Data Interchange (WEDI). It is designed to show the same type of         • You don’t have to buy a card reader to verify patient eligibility. Medicaid providers
  information shown on private health insurance cards.                                 can continue to verify eligibility by using a patient’s Medicaid ID number (PCN),

The front of the card will have:                                                       which will be printed on the card. Then you can:

• Client name and Medicaid ID number (patient control number – PCN)                   • Use the secure website— (after June 1)

• Managed care program name, if applicable (STAR, STAR Health, STAR+PLUS)             • Call the TMHP Contact Center at 1-800-925-9126

• Date the card was issued                                                            • Visiting TexMedConnect on the TMHP website

• Billing information for pharmacies

• Health plan names and plan phone numbers                                            Does having a card mean the client is eligible for Medicaid?

• Pharmacy and physician information for those in the Medicaid Limited program        No. Just because a patient has a Your Texas Benefits Medicaid card, it does not
                                                                                      necessarily mean he or she has Medicaid coverage. You must still verify eligibility.
The back of the card will have:
                                                                                      Patients will be instructed to keep their Your Texas Benefits Medicaid card even if
• A statewide toll-free number that clients can call if they need help or questions   their Medicaid coverage expires. The card can be reused if the patient later regains
  about using the card.                                                               Medicaid coverage.
• A website ( where they can get more information about
  the Medicaid card and access their personal Medicaid health history.
                                                                                      What if a client doesn’t bring the card to my office?
Important Note: The client website
                                                                                      If a member loses the Your Texas Benefits Medicaid card and needs quick proof of
will not be fully functional at the time
                                                                                      eligibility, HHSC staff can still generate a Temporary Medicaid Eligibility Verification
the cards are issued. This is reflected
                                                                                      Form (Form 1027-A). Members must apply for the temporary form in person at an
in our communications to clients.
                                                                                      HHSC benefits office. To find the nearest office, they can call 2-1-1 (pick a language
                                                                                      and then pick option 2).

                                                                                      After June 1 you can call this number: 1-855-827-3747
                               Texas Health Steps Corner                                                                                                  Claims Corner
Please save the date for this year’s Texas Health Steps Workshop that will take place                             EFFECTIVE: August 1, 2011 Invalid                  Can I send my corrected claim
on Friday August 5, 2011 at Region 19 ESC at Chito Samaniego from 8 am to 4 pm.                                   authorizations will be denied.                     electronically?
More details coming soon!                                                                                         • The Authorization Number should be submitted     Corrected claims may be sent electronically only

To register online please log on to this web address:                                                              should be in:                                     if the entire claim pay amount is ZERO. A zero                                • BOX 23 of the CMS 1500 for paper claims or;     paid claim is a straight denial. If the claim has a
                                                                                                                   • 2300 Loop Ref Segment with qualifier            partial payment, the claims should be submitted in
Auto-dialer and Reminder Postcard Initiative
                                                                                                                     code (G1); and                                  a paper format with the following documentation:
El Paso First has implemented an auto dialer system to remind our Medicaid                                         • 2400 Loop Ref Segment with qualifier            • Remit Advice
members that they are due for a Texas Health Steps (THSteps) checkup. Moreover,                                      code (G1).                                      • Corrected CMS 1500
we have created the enclosed postcard to remind them that they need to get a                                      • The authorization Number is 10 Characters Long   • Corrected claims form (Located on the website:
THSteps checkup. We would like to use the PCPs name to program the auto-dialer                                      with Prefix of Zeros. EXAMPLE: 0000123456 )
and send reminder postcards to the members in your panel/roster. Please let us know
if you are interested by contacting Michelle Anguiano, THSteps Coordinator at                                     All other characters submitted in the              Are the edits in the Correct Coding Initiative
915-298-7198 ext 1053 or via e-mail at                                                     authorization field will Deny with:                (CCI) Edits Manual valid for a whole year?
If you have any questions regarding the Texas Health Steps Program or would                                       • Denial Reason: Prior Authorization Not Found     No. The edits are updated on a quarterly basis.
like training for your staff, please contact Michelle Anguiano. Thank you for the                                                                                    However, the National Correct Coding Initiative
great health care you provide to our members!                                                                     DO NOT SEND:                                       (NCCI) Policy Manual is updated annually in
                                                                                                                   • CLIA Numbers: 45D0123456                        October.
                                                                                                                   • Auth NO Needed
                                                                                                                   • NOT 1st VISIT                                   Reference Questions from:
                            Health Services Corner                                                                 • EXPIRED                               
                         Maternal Value-Added Services                                                             • 117044

El Paso First Health Plans has a variety of services for our valued members.
Providers are able to link patients with the OB Unit and they can participate in
the following services: Transportation, Case Management, Monthly Baby Showers,
Car Seat Raffles, $20 Wal-Mart gift card.                                                                         The Authorization Number should be in BOX 23.

                                                                                               talk about

        celebrate                                joy with a Prenatal Cla
                                                                        ss just for you. We’ll

                                                          happy healthy
                                your bundle of                                                   . Enjoy
     Let’s                                                               and
                                w to keep your new
                                                               fre e gift                 waiting just for you!
                          to kno
     everything you need
                                                       e even have a

     fre e     refreshments, snacks
                                    and door prizes. W

           Car Seat

                              celebrate                          YOUR BUNDLE OF       joy
                                                                                         in 30 days
                                                                      e-natal class with
                                                     and come to a pr al-Mart gift card.
                           end a pre- natal check-up         receive a W
          Members who att with El Paso First are eligible to
                of enrolling
                                          Quality Improvement Corner
                                       Provider Accessibility and Availability Surveys

                                                       As part of our commitment to quality, El Paso
                                                       First monitors Primary Care (PCP) Providers
                                                       on an annual basis for 24-hour availability and
                                                       office accessibility appointment compliance.
                                                       PCPs and Specialists, specifically OB-GYN
                                                       and Behavioral Health Providers are surveyed
                               for office appointment accessibility. A random sample of PCP and
                               Specialists are selected on a quarterly basis. El Paso First will conduct
                               a face-to-face survey at your office to assess office appointment
                               standards. After-hours surveys are conducted after and/or before
                               regular office hours and during weekends to verify 24-hour availability.
                          Your partnership is paramount in the success of our Quality Improvement
                          initiatives and requirements mandated by Texas Health and Human Services
                          Commission (HHSC) and Texas Department of Insurance (TDI).

1145 Westmoreland Drive
El Paso, TX 79925-5615

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