Basic HTML Version
E
Provider Newsletter
Summer 2012
2
Benefit changes
3
TVFC updated eligibility policy
4
Filing claims
INSIDE
Quarterly
Health
Attention Providers!
The new Provider Manual, effective
March 1, 2012, is available online at
www.epfirst.com/pdf /providermanual.pdf
.
The most important updates
include pharmacy information on our
Pharmacy Benefit Manager and how
the prior authorization process and the
72-hour override work. You’ll also find
a table with the new CHIP cost-sharing
and co-pay updates along with helpful
attachments, such as the often-used
prior authorization forms.
You can download the manual
for easy access to information
that pertains to your rights and
responsibilities as part of our Provider
network. Thank you for the great health
care you provide to our members!
El Paso First Health Plans Inc. (El Paso
First) has contracted with Navitus Health
Solutions to provide pharmacy services
to our Medicaid and CHIP members. A
quick reference guide is available on our
website as well as the Pharmacy Direc-
tory and Pharmacy Provider Manual.
Links to the Texas Vendor Drug Formu-
lary and Preferred Drug List can also be
found on our website under the “Provid-
ers” section by clicking on “Links.”
Prescribers can access prior authoriza-
tion (PA) forms online via
www.navitus
.com
under the “Providers” section or
have them faxed by Customer Care to
the prescriber’s office. Prescribers will
need their NPI and state to access the
portal. Completed forms can be faxed
New Pharmacy
Benefit Manager
24/7 to Navitus at
920-735-5312
.
Prescribers can also call Navitus Cus-
tomer Care at
877-908-6023
. Providers
can select the prescriber option and
speak with the department Monday
through Friday between 8 a.m. and
6 p.m. Central time to submit a PA re-
quest over the phone. After hours, Pro-
viders can leave a voice mail message.
Decisions regarding prior authoriza-
tions will be made within 24 hours
from the time Navitus receives the PA
request. The Provider will be notified by
fax regarding the outcome—or verbally
if an approval can be established during
a phone request.
Pharmacies will submit pharmacy
claims to Navitus. Medications that
require PA will undergo an automated
review to determine if the necessary
criteria have been met.
When a PA is required and the Pro-
vider is not available to submit the PA
request, HHSC requires pharmacies to
dispense a 72-hour supply as long as
the member will not be harmed if the
PA is denied and therapy is discon-
tinued. The 72-hour emergency fill is
for any Medicaid STAR or CHIP/CHIP
Perinatal recipients. If a pharmacy
does not comply with the 72-hour
emergency fill requirement, it can be
reported to the HHSC Office of Inspec-
tor General and the Navitus Network
Department at
608-729-1577
for
review.