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The Texas Vaccines for Children
(TVFC) program is available at no cost
to Providers and is part of providing
a comprehensive care package to
patients. TVFC’s updated eligibility
policy has changed:
Children younger than 18 years
old who meet at least one of the fol-
lowing criteria are eligible to receive
a TVFC vaccine from any enrolled
Provider:
DELIVERY INDUCTION
AUDITS
The new process was implemented in
December 2011. The purpose of these
reviews is to ensure medical necessity
for all delivery inductions and cesarean
sections scheduled before 39 weeks.
In this process:
■
El Paso First Health Plan pulls a
system-generated random selection of
15 monthly claims with modifiers U1,
U2 and U3.
■
El Paso First sends a letter to the Pro-
vider requesting medical records. The
turnaround time for receiving medical
records is 15 days.
■
After El Paso First receives the
medical records, El Paso First’s medical
director reviews the records for medical
necessity of the induction.
■
El Paso First will notify the Provider
of findings. If the medical records reveal
that there was no medical necessity for
the induction, El Paso First will recover
all payments paid for the delivery.
MEMBER MEDICAL
SERVICES VERIFICATIONS
This new process was implemented in
December 2011 to ensure services were
TVFC PROGRAM
Updated eligibility policy
■
Medicaid-eligible.
■
Uninsured.
■
American Indian or Alaska Native.
■
Underinsured, defined as: A child
who has commercial health insur-
ance, but coverage does not include
vaccines; a child whose insurance
covers only selected vaccines (TVFC-
eligible for noncovered vaccines
only); or a child whose insurance
caps vaccine coverage at a certain
amount. Once that coverage amount
is reached, that child is categorized as
underinsured.
For more information on TVFC, go
to
www.dshs.state.tx.us/immunize/tvfc/
default.shtm
.
You are encouraged to use ImmTrac,
a centralized system for recording im-
munizations electronically. To learn
more, go to
www.dshs.state.tx.us/
immunize/immtrac/default.shtm
.
El Paso First initiates new
mandated requirements
rendered as billed.
In this process:
■
El Paso First pulls a system-
generated weekly random selection of
15 claims.
■
El Paso First’s Special Investigations
Unit auditor phones our member or
the member’s legal representative and
asks if he or she received services on the
identified date of service.
If you have any questions or con-
cerns, contact:
Laura E. Wilson, BSHCS, CCS-P
Special Investigations Unit, Claims Auditor
915-298-7198 ext. 1169
lwilson@epfirst.com