Welcome

Please Note:

Paper claim submissions will continue to go to:

El Paso First Health Plans –Claims

P. O. Box 971370 El Paso, Tx 79997-1370

Our general correspondence address will not change:

P.O. Box 971100 El Paso, Tx 79997-1100

1145 Westmoreland Drive El Paso, Tx 79925-5615

Department Extension Fax number DescriptionMember Services STAR 1514

STAR Sp1518 CHIP 1517 CHIP Sp 1519HCO 1502TPA 1529

915-532-2286 Eligibility

Health Services 1500 915-298-7866(pre-authorizations)

Pre-authorizations & Case Management

PCU PCU-1504 915-298-7867 Claims status & Corrections

El Paso First Departments Contact Information

Main number: 915-532-3778

Provider Information

In order to have the most updated/ accurate information in our system and in our directories please provide any type of changes to Sun City.

El Paso First Health PlansBehavioral Health Unit Health

Services Department

Pre-Authorization Overview

∙ Pre-Authorization requirements ∙ Pre-Authorization process flow ∙ Pre-Certification Form for Behavioral Health Services ∙ Completion of the Pre-Certification Form

-Frequently Asked Questions

Pre-Authorization Requirements

• Initial evaluations do not require an authorization (CPT Code 90801)

• Subsequent visits for individual and/or family visits require an authorization

Pre-Authorization Requirements

• Pre-Certification form must be faxed to the Behavioral Health Unit at 298-7866 for all inpatient and outpatient requests

• Behavioral Health Unit will turn around authorizations within 72 hours

Pre-Authorization Process Flow

Pre-Authorization Process Flow

• Providers may call the Behavioral Health Unit directly for questions regarding the status of the authorization request

• Contact information– 532-3778 x 1500

Pre-Certification Form

Pre-Certification Form (pg. 2)

Completing the Pre-Certification Form

• Complete the member’s identifying information so an authorization can be generated – Member’s name– Health plan identification number– Date of birth

Completing the Pre-Certification Form

• For initial requests, please provide a brief narrative of the member’s clinical presentation • This information should be entered under

“Evaluation of initial treatment”• For continuation requests, please include a

summary of why services need to continue • This information should be included under “For

continuation of therapy requests . . .”

Pre-Authorization: Frequently Asked Questions

• What is the difference between date of admission and date of procedure?– Admission date – The date a member is admitted to an

inpatient facility– Date of procedure – The date the provider is going to

conduct the requested CPT Code (i.e. 90806, 90847)

• Do I fill out CPT Codes or Revenue Codes (Rev Codes)?– CPT Codes are common for most outpatient providers– Revenue Codes are used by facility providers (i.e.

psychiatric hospitals)

Pre-Authorization: Frequently Asked Questions

• How many sessions are authorized? – Medical director will review the number of units

requested by the provider and make a decision based on medical necessity

• How much information is necessary for the pre-certification form? – Brief description that paints a clinical picture of the

individual– Updated clinical information is important for

continuation requests

Modification of Services Denial of Services

Modification of Services • The Medical Director has approved

services with a modification from the original request

• Example: – Provider requests date of service

from 01/29/10 – 11/10/10– Medical Director approves a date of

service from 01/29/10 – 04/29/10• The provider will receive a fax

notifying him/her of the modification and an opportunity to discuss the services that were not approved

Denial of Services

• The Medical Director has not approved the requested services

• Example: – No clinical information is submitted

with the pre-certification form– Incorrect ICD-9/DSM-IV-TR

• The provider will receive a fax notifying him/her of the denial. A denial letter with appeal rights will

be mailed to the provider.

Reasons for a Modification or Denial of Services

Modification of Services • Dates of service

– Retro authorization• Number of units for CPT

Codes that do not meet medical necessity

Denial of Services • Incorrect DSM-IV-TR Code• Duplication of services

Claims Department

Sonia Lopez- Director of Claims

Submission Process

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Payer Name Payer ID

Medicaid-TX Premier Plan (STAR HMO) EPF02

El Paso First- CHIP EPF03

Preferred Administrator EPF10

Healthcare Options / Care Management EPF37

CLAIM PROOF OF TIMELY FILING

Submit a copy of an Electronic Claims Report that includes the following information:

Batch submission ID and date Individual claim that is being appealed EL Paso First -assigned batch ID number

CMS 1500

Additional Information Rejection Form

Claim Filing Deadlines

Claims must be received by El Paso First within 95 days from DOS

Corrected claims must be re-submitted within 120 days from the R.A. (Remittance Advice)

When a service is billed to another insurance resource, the filing deadline is 95 days from the date of the disposition by the other insurance carrier.

It is strongly recommended providers who submit paper claims keep a copy of the documentation they send. It is also recommended paper claims be sent by certified mail with return receipt requested & a detailed listing of the claims enclosed.

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Member Service Helpline

(915)-532-3778 or 1-877-532-3778

Office Business Hours Monday- Friday 8:00 AM – 5:00 PMHours of call center operation 7:00 AM – 6:00 PMAfter Hour on call 24 hours a day 7 days a week.

El Paso First El Paso First ProgramsPrograms

El Paso Premier Plan/STAREl Paso Premier Plan/STAR∙ ∙ El Paso First Premier Plan - STAR Medicaid Program

∙ ∙ Medicaid is a program that offers health and long-term care services to certain persons who have limited income, are pregnant, and/or persons with disabilities

El Paso First CHIP (Children’s Health Insurance Program)El Paso First CHIP (Children’s Health Insurance Program) ∙ A program designed for families who earn too much money to qualify for

Medicaid, yet can not afford to buy private insurance.∙ Membership includes children ages 0-19 & enrollment for 12 months ∙ Certain services may require CHIP member co-payments

El Paso First El Paso First ProgramsPrograms

El Paso First CHIP Perinatal Program El Paso First CHIP Perinatal Program ∙ ∙ CHIP Perinatal provides prenatal care to unborn children or pregnant women up to 200% of FPL and who are not eligible for Medicaid or traditional CHIP.

∙ ∙ The unborn child is enrolled in CHIP Perinatal and once born, will receive full CHIP benefits for the duration of the 12 month coverage period

∙ ∙ CHIP Perinatal members have no co-payments

Preferred AdministratorsPreferred Administrators ∙ ∙ El Paso First Health Plans, (dba Preferred Administrators) is the Third Party Administrator (TPA) for the El Paso County Hospital District. Preferred Administrators is the TPA that manages the health care benefits for the County Hospital District.

El Paso First Health Plans Behavioral Health & Substance Abuse Crisis

Line

For behavioral, personal, family problems and substance abuse such as alcohol or drugs.

(915) 351-1264 or 1-866-944-6467

Crisis Line available 24/7/365

Questions???

Employee Assistance Program

Sun City’s Mission

• Improve the availability and quality of behavioral health

services in El Paso

• Ensure that our EAP services are being delivered in the

most effective and efficient manner

• Provide our EAP members with an array of choice for mental health & substance

abuse services, as well as the convenience to access a provider close to home,

school, or work

Sun City’s New Location

Sun City Behavioral Health Care» 2929-B Montana Ave

El Paso, Texas 79903» Phone # 915-351-4680» Fax # 915-351-3643

From: Sun City Behavioral Health Care 616 N. Virginia St

El Paso, Texas 79902

Sun City Behavioral Health Care

Our New Location!!

•We are right across from Police Headquarters on Montana•Located inside the “Sun City Medical Plaza”

Behavioral Services

• Over 215 Behavioral Health Providers available – Licensed Professional Counselors– Licensed Marriage & Family Therapists (LMFT)– Licensed Clinical Social Workers (LCSW)– PhD level Psychologists– Psychiatrists (Child & Adult)

• Offer 3 to 8 sessions per year (dependent on the plan chosen by the employer)

High Quality of Services

• Extensive choice of providers– Conveniently located throughout the El Paso

County

• Licensed professionals– Undergo strict credentialing process

• Recognized in the local community for their quality of service

• Offer approximately 130 counselors that can provide counseling in English & Spanish (Other counselors fluent in French, German, Hebrew, and Russian)

Sun City EAP Process – EAP Referral Letter from Sun City

• Includes name (s) of eligible members • Member must provide on day of initial assessment

– Pre-Authorization Fax Form • Must be filled out by provider• Faxed to 915-351-3643• Sun City will return authorization within 7 days

– Discharge Summary• Must be completed by provider within 2 weeks after discharge• Faxed to 915-351-3643

2929 Montana Ave Ste B El Paso, TX 79903 Ph: 915-351-4680 Fax 915-351-3643

February 25, 2010 Per agreement between Sun City Behavioral Healthcare (“Sun City”) and Kristen Daugherty, LISW-LCSW, John Doe, an Employee Assistant Program (“EAP”) member is eligible for services. Please submit Pre-Authorization Form after initial visit to 915-351-3643 (Fax)

* Notify Sun City, prior to submitting claim, if you do not have a copy of the pre- authorization fax form.

_________________________________________________________________________________ Kristen Daugherty, LISW-LCSW 2929 Montana Ave. Ste. B El Paso, TX 79903 (915) 351-4680 Name of EAP Member: John Doe Authorization: ________________________ Ashley Sandoval Ashley Sandoval Member Services Representative Sun City Behavioral Health Care 915-351-4680

What are Mandatory Referrals?

• At times, the employer may find it necessary to obligate the employee to attend counseling on a mandatory basis.

• Typically Mandatory referrals are the result of absenteeism, substance abuse, violation of company policy and procedures, etc.

• Employers require compliance with treatment recommendations and can be requested on a weekly, bimonthly, or monthly basis.

2929 Montana Suite B. El Paso, TX 79903 Phone (915) 351-4680 Fax (915) 351-3643

Release of Information for Employee Mandated Referral (To be completed by designee and given to employee to review and sign)

I, John Doe, understand that I am being mandated to contact Sun City EAP to receive a referral due to my violation of company policy and procedure. I furthermore authorize Sun City EAP and/or individuals or entities named below to disclose to one another and receive from each other pertinent and relevant information regarding:

1. My contact with Sun City EAP- I must contact Sun City on or before this date: Date HR has referred employee 2. My drug and alcohol test results and/or my documented job performance issues: Please state cause for mandatory referral 3. The synopsis of my treatment plan (i.e. use of insurance benefits; use of remaining EAP sessions) 4. My compliance with treatment recommendations Compliance Reports will be faxed to Supervisor/MRO: indicate one Weekly Bimonthly Monthly Only if Non-Compliant N/A only mandating contact 5. Back to work conference with employee& counselor (only if employee is absent from work place due to treatment)

Primary Contact _______________________________ Phone: ____________________________ (Name, Title)

Fax: _________________________ is this a secured/confidential fax? Yes No

Secondary Contact ___________________________ Phone: _______________________________ Fax: _________________________ is this a secured/confidential fax? Yes No

Employee work Status Active Receiving full pay On paid leave On unpaid leave Terminated This Employee is being mandated for:

Failed Drug/Alcohol Screen: Company Violation Other Reason for Drug/ Alcohol Screen Random For Cause Post Accident Pre-employment Date& Location of Drug/ Alcohol Screen: ________________________________________________ Result of Drug/Alcohol Screen: ________________________________________________

DOCUMENTED JOB PERFORMANCE ISSUE: _____________________________________________________ Statement of company policy violation- related documentation may be attached

Verbal Warning Written Warning Final Warning ** Employee must show improvement by this date: ___________________________________________ ** Sun City EAP will monitor compliance for up to 6 weeks on the Job Performance Issues

I understand that I may revoke this contract at any time except at the extent that action has already been taken in reliance hereon, and, if not revoked sooner in writing, this consent will expire at case closure from the date signed. A copy of this release of information is valid. To receiving party of this information: This information has been disclosed to you for the sole purpose stated in this consent. Any other use of this information without expressed written consent of the employee is prohibited. The records may be protected by Federal Regulations (42 CFR part 2) _________________________________ ________________________________________ Employee Date Witness Date

Follow up Program

• Our standard follow up program will be conducted, by a Sun City Representative, 3 months after the member has been discharged from the provider

• The member will be asked to rate Sun City EAP on the following areas

1. Accessibility 2. Referral Process3. Satisfaction with Provider/Treatment4. Overall Satisfaction with EAP Program

Telephone: (915) 351-4680, Fax: (915)351-3643

Aftercare Follow- Up Form

1. Sun City’s I ntake process was prompt and trouble-f ree

2. Sun City’s Staff was professional and responsive

3. Sun City’s Referral process took place within 24 hours

4. Sun City’s ref erral process ensured the provider accepted my private insurance

5. My scheduled appointment was within 7 days

6. Provider was understanding of my problems

7. I did not have the need to change my provider

8. My problems were resolved within the allotted sessions

9. I did not need to access my private insurance to continue services.

10. Sun City’s staff preformed a f ollow up phone call once I was discharged f rom my provider

11. Overall I was satisfi ed with my EAP provider

12. Overall I was satisfi ed with my EAP services

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Claims Process

• Claims should be submitted to Sun City within 30 days of the date of service.

• All EAP Claims will be processed for payment within 30 days of receipt.

Discharge Summary

• Sun City will begin supplying all EAP providers with a “ Discharge Summary”

• Discharge Summary:– HIPPA Compliant – Needs to be faxed to Sun City within 2 weeks of

the member’s discharge from your program

Instructions: The Sun City Behavioral Health Care Discharge Summary is HIPAA compliant and is to be FAXED to Sun City within 2 weeks of the member’s discharge from your program.

1.Disposition (REQUIRED) Check only one COMPLETE at final session 2. CURRENT LEVEL of JOB IMPACT (REQUIRED)

Yes No

Please Mark

Resolved within _________EAP visits None

Continuing to see this member under his/her Mental Health benefit or under alternate coverage. I certify that there is no conflict of interest and member has been informed of alternate referrals. Minimal

Referral to another clinician @: Moderate

Referral to structured outpatient program @: Significant – No Job Jeopardy

Referral to inpatient program @: Significant – Job Jeopardy

Referral to Partial Hospitalization @: Undisclosed/ Not Applicable

Referral to Community Resources @:

Referral to Medication Management @: FORM COMPLETED BY (PRINT): SIGNATURE: DATE:

DISCHARGE INFORMATION Member’s Initial and Authorization Number: Date of Discharge Report: Provider: Reason for Discharge: Status at Time of Discharge: Improved/stable Improved/not stable Unimproved Worse Unknown Please highlight and delete the answers that do not apply, leaving only the appropriate answer. Date of Last Face-to-Face Appointment Prior to Discharge: DISCHARGE DIAGNOSIS (ALL AXES REQUIRED)

AXIS I:

AXIS II:

AXIS III: AXIS IV: None Mild Moderate Severe; Describe: Please highlight and delete the answers that do not apply, leaving only the appropriate answer. AXIS V: GAF-Current: Past GAF:

Medication At Discharge NAME: DOSAGE: FREQUENCY: Comments

1. Call 1-877-560-8730 (Toll-Free) or 915-351-4680 (Main Office)

2. Describe your concerns to Care Coordinator3. Care Coordinator will evaluate your situation4. An appropriate plan will be developed for you5. You will be linked to the appropriate Provider6. Care Coordinator will provide you with coordination and

guidance while accessing EAP services7. You will receive a referral letter to take to the provider to

receive the services8. If long term services are needed, the Care Coordinator will

assist you in accessing your insurance benefits or referring you to community resources

9. Follow-up will be provided to ensure that all your needs were met

How do Employees access their EAP benefits?

• Who is eligible for Sun City EAP services?– Employee– Immediate family members– Dependents

• When are Sun City EAP services available?– Monday – Friday– 8:00 – 5:00– Crisis Line *

• 24 hrs a day• 7 days a week

• How much will Sun City EAP cost me?– Your behavioral services have been pre-paid by your

employer so they are free of charge to you– Other services are offered at discounted rates

Frequently Asked Questions

Employee Confidentialityis protected by Federal Law.

All calls, accessibility of service and counseling sessions are strictly confidential.

All records are kept at Sun City Behavioral Health and do not go to your employee file.

Sun City reevaluates the past and faces the present while preparing

for the future.We are here to assist you

Thank You!