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Provider
NEWS
A publication of Texas Children’s Health Plan
Summer 2013
Texas Children’s Health Plan has a new website!
To better serve our members and providers, Texas Children’s
Health Plan is introducing an all-new, innovative, and optimal
website. Now our members can read valuable health-related
information, receive up-to-date events information,
and much more.
Our new website is now optimized for mobile devices,
including cell phones and tablets, so you can view forms,
guidelines, and other important information on the go. We
now have a Provider Relations page so you can know who
to call and how to reach them.
We know you will be impressed with the new site, so go
to www.TexasChildrensHealthPlan.org to see for yourself.
ND-0713-119
Texas Children’s Health Plan, Inc.
P.O. Box 301011, NB 8301
Houston, Texas 77230
NONPROFIT ORG.
U.S. POSTAGE
PAID
PERMIT NO. 4
HOUSTON, TX
Medical Director Corner
On October 14, 2014,
the International
Classification of Disease,
9th Edition (ICD-9) code
sets used to report medical
diagnoses and inpatient
procedures will be
replaced by International
Classification of Disease,
10th Edition (ICD-10)
Dr. Angelo Giardino
code sets. The change
from ICD-9 to ICD-10 will enable physicians’ offices to
collect and share more detailed patient data. This process
change will affect all physician practices and hospitals.
Here is what you, as a practitioner, should know
about ICD-10:
• I CD-10 has 3 to 7 alphanumeric digits instead of the
3 to 5 numeric digits in ICD-9.
• A
ll electronic transactions must use Version 5010
standard, which have been required since
January 1, 2012.
• I CD-10 diagnosis codes must be used for all healthcare services. Claims with ICD-9 codes for services
provided on or after the compliance deadlines
cannot be paid.
• R
e-think the way you document. There is a plethora
of specific codes, and it requires that you be very
specific in documentation. Therefore, take the time
to gather the information, and put it in the
patient’s record.
Finally, American Medical Association (AMA) has
published the “ICD-10 Timeline: Meeting the
Compliance Data” to help you with your office
preparation. This is available free of charge at
http://www.ama-assn.org/resources/doc/washington/
icd10-timeline-fact-sheet.pdf.
Adolescent Transitions Part 3:
Insurance changes during transitioning
Changes in health coverage can be an obstacle for the
adolescent patient between the ages of 18 to 26 years
of age. Adolescents who are healthy and on public
health coverage plans will lose coverage around the
age of 19. Those adolescents with chronic health
conditions (such as Asthma and Type 1 Diabetes) are
also vulnerable due to changing eligibility criteria for
coverage with public health coverage plans for adults.
Adolescents who areon private health coverage plans
with their parents may be able to continue to age 26
per the Affordable Care Act (ACA).
Given these risks for gaps in health coverage, it is
important to guide transitioning young adults and their
families to available resources. The pediatric provider
needs to discuss with their adolescent patient and family
the changes that may occur, and develop a plan for
ongoing health care well before the time of transition.
If the adolescent loses public health coverage and can’t
be covered by family employer-based plans, safety net
clinics are an option as are college health plans.
2
In 2014 many adolescents will have access to more
affordable healthcare options, so stay tuned to upcoming
changes with the ACA. The Texas Department of
Insurance has a website with information on health
coverage programs that individuals can purchase:
http://www.tdi.texas.gov/health/index.html.
To qualify for adult Medicaid in the state of Texas, the
patient would need to have a severe disability and meet
certain income requirements. For more information,
access this website:
http://www.hhsc.state.tx.us/help/index.shtml.
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
A message from our President
Texas Children’s has been innovating for the past
50 years by focusing on patient care, education,
and research. For the past 18 years, Texas Children’s
Hospital has been focusing on care delivery models for
the members we serve. In the mid-1990’s, we created
Texas Children’s Pediatrics, which has become one
of the nation’s largest and most successful pediatric
independent practice associations.
In addition to improved quality, we are striving to
improve patient access. On any given day, 20 percent
of our 1,200 primary care physicians have closed
their panels to new members. The Center will offer
substantial extended hours and technology to reduce
unnecessary ER visits, hospital admissions and
re-admissions. These initiatives will also help control
our pharmaceutical utilization.
Texas Children’s created Texas Children’s Health Plan
in 1996. We enrolled our first CHIP member in 2000,
our first Medicaid member in 2002, and we have
grown to become the largest Medicaid and CHIP
health maintenance organization in the Harris and
Jefferson Service Areas.
We value the partnerships we have maintained with
our providers since 1997, and we wish to continue
that partnership as we have always done. Because
we feel that personal relationships and assistance
with your practices are important, we have Provider
Relations Managers for you to call with questions
and who can make personal visits to your office
for multiple reasons such as to train you on new
systems, update you on any changes, and ensure your
satisfaction with Texas Children’s Health Plan. For
our members, we have an excellent team of Member
Services Representatives who your patients can call for
any questions they have about their health coverage.
Our innovation does not stop there. Texas Children’s
Health Plan will introduce The Center for Children
and Women in August of this year. The Center is
a new kind of facility designed to improve access,
quality, and patient satisfaction while bending the cost
curve. It is based on medical home principles proven
in peer review literature to improve the quality of the
patient experience, outcomes, and cost reductions.
The Center is lead by physicians and integrated teams,
and we support those teams with enhanced carecoordination, patient education, and just-in-time
patient support.
The Texas Health and Human Services Commission
(HHSC), which manages the Medicaid and CHIP
programs in Texas, is holding all HMOs across
the state to higher quality-based outcomes and is
penalizing us if our network performance on key
quality ratings is less than standard. Therefore, we
are seeking to develop new care models that reward
physician-lead teams based on quality and wellness
rather than volume-based systems. In other words, The
Center rewards physicians for a well visit engine as
opposed to a sick visit engine.
The health care world is changing. Texas Children’s
is leading the change, and we want you to be on this
journey with us.
Sincerely,
Christopher M. Born
President, Texas Children’s Health Plan
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
3
Look for the next CME session.
Thursday, September 5, 2013
More information will follow.
Texas Children’s Health Plan moves to
Automated Credentialing: AppCentral
Texas Children’s Health Plan will be moving to an
automated credentialing system called AppCentral for
all providers. The AppCentral process allows the
provider and Texas Children’s Health Plan to process
all credentialing applications and documents through
a web portal.
In phase one providers serving Texas Children’s Health
Plan will start the credentialing process through
AppCentral. The provider will receive an e-mail
invitation asking them to click on the link in the e-mail
and create a user account for AppCentral. From this
point, all information provided for the credentialing
process is done through the AppCentral website. In the
event that Texas Children’s Health Plan needs further
information, an e-mail will be sent prompting the
provider to submit the needed items via AppCentral.
Electronic communication via AppCentral is completed
once Texas Children’s Health Plan receives all items and
accepts the application.
application will be uploaded into AppCentral with the
current information we have on the provider in our
system. The provider will verify all of the information
and will also submit any further needed documents. If
Texas Children’s Health Plan needs further information,
an e-mail will be sent prompting the provider to submit
the needed items via the AppCentral website. In the
coming months your Provider Relations Manager will be
requesting an e-mail address from you that will be used
for this process. It is imperative that you provide Texas
Children’s Health Plan with a reliable e-mail address to
avoid any interruptions in your participation with us.
We firmly believe the AppCentral process will be more
efficient for both our new and existing providers, as well
as streamlining the credentialing process. If you have
any questions regarding this process, please contact your
Provider Relations Manager for further details.
Phase two of the AppCentral process will allow
participating providers to complete the recredentialing
process; however a date has not yet been established.
Upon initiating the process for re-credentialing, the
provider will also receive an invitation via e-mail to
register with AppCentral. A prepopulated credentialing
4
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
Infant Apnea Monitors
a technology whose time has come… and gone
Apnea monitors sounded like a good idea… at first.
Parents fear crib death (sudden infant death syndrome
or SIDS). The only problem is that home infant apnea
monitoring does not work to prevent SIDS. Monitors
do not prevent crib death. They cause parents a great
deal of anxiety because of false alarms. Abnormal
findings on apnea monitoring have no predictive value
as to risk for future crib death or near death events.
This has lead the American Academy of Pediatrics
to conclude, “Given the lack of evidence that home
cardiorespiratory monitoring has any impact on SIDS,
prevention of SIDS is not an acceptable indication for
home cardiorespiratory monitoring.”1
Whether to use an apnea monitor for apnea of
prematurity is controversial. The American Academy of
Pediatrics Guidelines (2003) advise that, if considered,
that monitoring be reserved only for those preterm
infants with “an unusually prolonged course of
recurrent, extreme apnea,”and that apnea monitoring
can usually be discontinued by 43 weeks post menstrual
age as respiratory centers will have sufficiently matured.2
On the other hand, many experts feel that once the
premature infant is clinically stable for discharge that
home apnea monitoring does not provide any
additional benefit.
There are truly effective things that can be done to
prevent crib death. Three of the most important are
‘back to sleep,’ breastfeeding, and elimination of smoke
exposure.2 Infants should sleep supine (face up) and
sleep surface should be firm without any soft or loose
bedding or pillows.1 Tobacco dependent parents and
caregivers are the infant’s most important source of
tobacco smoke exposure.
Effective tobacco dependence treatment is available. Free
help with tobacco dependence treatment is available
from the state telephone quitline at 1-800-QUIT-NOW.
Give this phone number to every tobacco dependent
parent or caregiver.3
By Harold J. Farber, MD, MSPH and Michael E. Speer, MD.
From the American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. Policy Statement: SIDS and Other Sleep-Related
Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011; 128:5 1030-1039
1
References: American Academy of Pediatrics Committee on Fetus and Newborn. Apnea, Sudden Infant Death Syndrome, and Home Monitoring.
Pediatrics 2003; 111:4 914-917.
2
The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is a validated program with 3 simple steps (Ask, Assist, Refer) that can be easily
implemented in pediatrician’s offices. The program materials are available free at http://www2.massgeneral.org/ceasetobacco/
3
Additional Resources: The American College of Chest Physicians Tobacco Dependence Treatment Toolkit is available free at
http://tobaccodependence.chestnet.org/
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
5
Texas Children’s Health Plan Therapy Guide
The below guidelines, effective August 1, 2013, are provided for your assistance in requesting prior authorization
for therapy services.
It is Texas Children’s Health Plan’s policy to authorize
all therapy for medical necessity. Protocol and/or
authorizations are evaluated, reviewed and supported
by the Medical Director and Associate Medical
Director(s), who are experienced physicians with a
strong understanding of patient need and expected
clinical outcomes associated with outpatient therapy.
Therapy services delivered by Early Childhood
Intervention providers do not require authorization.
Requests for prior authorization of chronic therapy
services, which must be initiated by a physician, can be
made by phone or fax by contacting Texas Children’s
Health Plan at:
Phone: 832-828-1004
Fax: 832-825-8760
Authorization is not provided for retroactive dates of
services. Texas Children’s Health Plan advises submitting
requests 5 business days prior to the desired start date to
allow for processing time.
Initial Evaluation Request: Authorization MUST be submitted by the referring physician prior to evaluation and
must include the name of the therapy entity to conduct
the evaluation.
• The evaluation order must specify disciplines to
evaluate and be signed (no stamped signatures) by the
primary care physician, neurologist, orthopedic physician, or rehabilitation physician and specify the diagnosis and medical reason for the therapy evaluation.
• Must include the most recent complete Texas Health
Steps medical checkup (as applicable; exams must be
up to date in accord with the periodicity schedule).
• Current development screen (within last 30 days)
documenting significant delay in area of evaluation request (ASQ or PEDS screening may be used
through age 6). Comment of assessment of normal
intelligence.
• Include provision for a home exercise program (HEP)
with frequency that the parent/caregiver is to perform
the HEP.
• Document current (last 6 months) hearing screening
for ages 0 to 3 years or current (past 12 months) for
ages 3 years, 1 month to 6 years if request is for speech
therapy addressing communication delays/deficits.
• Audiological assessment to be submitted for any failed
hearing examination as well as treatment in place.
• Acute conditions (for example, a broken arm) do
not require additional information beyond current
Texas Health Steps medical checkup for an evaluation
request however authorization is required.
6 Month Re-Evaluation Requests (to be requested less
than 30 days prior to expiration or authorization):
• Documentation from the primary care physician,
neurologist, orthopedic physician, or rehabilitation physician, identifying the medical necessity for
reevaluation must be submitted for services extending
beyond 6 months in duration, as well as the specific
disciplines to evaluate noting the member’s progress
to goals and home program adherence.
• If the member has transferred to Texas Children’s
Health Plan coverage from another health plan, documentation of the initial authorization information and
treatment plan must be submitted. Texas Children’s
Health Plan will honor documented authorizations
from the previous health plan for the shorter of 90
days or until the expiration of the authorization.
Initial Treatment Requests (post evaluation):
Treatment orders must specify frequency and duration of
the requested services must be signed by the primary care
physician (no stamps) and submitted to Texas Children’s
Health Plan (may come from the therapy provider) with
a plan of care indicating prior treatment (as pertinent),
medical status, current level of functioning, standardized
assessment scores, age equivalents, percentage of functional delay, or criterion-referenced scores relating to the
member’s condition.
• A diagnosis and prognosis as well as treatment modalities and recommended frequency/duration with short
and long-term goals specific to the member’s
condition/impairment must be included.
Continues on page 7
6
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
Texas Children’s Health Plan Therapy Guide
Continued from page 6
• Occupational therapy is not considered medically
necessary for attention deficit hyperactivity disorder,
sensory processing disorder, feeding disorder, or
learning skills for the classroom environment.
• For speech therapy, documentation of the member’s
dominant primary language is required. Speech is
not considered medically necessary for educational,
cognitive, or behavioral reasons.
Reauthorization of Ongoing Treatment Requests
(previously authorized by Texas Children’s Health Plan):
• Objective demonstration of member’s progress toward
goals included.
• Explanation of changes in condition is documented
as applicable.
• Explanation of parent/guardian participation and
home therapy plan adherence.
• Documentation of attendance and parent/guardian
in attendance.
• Estimate of intelligibility and statement of communication skill level for speech therapy services.
Members under the age of 3 years old should receive
therapy services from Early Childhood Intervention
unless compelling reasons such as major medical diagnoses, high acuity medical needs, or severe to profound
developmental delay exist. For Medicaid members,
therapy providers are required to refer children younger
than 35 months to Early Childhood Intervention within
2 business days of identification, according to Sec. 5.1.5
of the Texas Medicaid Providers Manual.
In addition, therapy providers must refer preschool
children to Head Start or to their school district for
evaluation for inclusion in the Preschool Program for
Children with Disabilities (PPCD), depending on the
severity of the child’s developmental delay, or provide
documentation of parent/guardian refusal. If the child
is enrolled in school, therapy providers must coordinate
services with the school, including obtaining a release
of information or document parent/guardian
refusal to consent.
Over-the-counter medications
Texas Children’s Health Plan STAR members are able to
obtain over-the-counter (OTC) medications at the local
pharmacy in the same way they can obtain any other
prescription. Providers only need to write the prescription,
and the member can then obtain the OTC at their local
Texas Children’s Health Plan-contracted pharmacy.
In the first quarter of 2013, the following OTC
medications are the top OTC medications prescribed
for our STAR members.
Ibuprofen
Q-PAP
Loratadine
Ibuprofen Childrens
Sea Soft Nasal Mist
TL-Hist DM
Q-PAP Childrens
Centirizine HCL Childrens
Children’s Ibuprofen
Pain & Fever Childrens
Vanacof DX
Alahist DM
Deep Sea Nasal Spray
Vanacof
Chlo Tuss
Loratadine Childrens
Oralyte
Cetirizine HCL
Childresn Loratadine
Lohist DM
Q-Dryl
Pediatric Electrolyte
Dr Smiths Diaper
Hydrocortisone
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
7
It’s seasonal allergy time: Help your patients with 3 simple steps
Ah the flowers, the trees in bloom, you can almost smell
the pollen filling the air. For many patients summer and
spring can be peak times for seasonal allergies. With
just 3 simple steps we can do a lot to help our patients
through the allergy season.
Step 1: Try to reduce exposure. Keep windows closed
when possible. As pollen levels tend to be highest in
the morning and early afternoon, try to schedule
outdoor activities late in the day. Cut down on things
in the home that can make allergies worse — such as
smoke and strong chemicals. Free help for tobacco
dependent parents is available from the state quitline
at 1-800-QUIT-NOW(operated by the American
Cancer Society).
Step 2: Antihistamines are still the best place to start
with treatment. Antihistamines work best BEFORE
the histamine is released; it should be used daily during
the allergy season (especially if the patient anticipates
exposure to their allergen). Non-sedating antihistamines
such as loratadine and cetirizine are effective and well
accepted by patients. Loratadine and cetirzine as 10 mg
pills and 5 mg/5 ml liquid are on formulary and can be
covered with a physician’s prescription.
Step 3: If an antihistamine is not sufficient, consider
addition of a nasal topical corticosteroid. Fluticasone
nasal spray is available generically, is on formulary, and
is often a good choice to start with. The major side effect
of topical steroid nasal sprays is nosebleeds. As most
bleeding is from the nasal septum, advise patients to aim
spray back and towards the side. To facilitate this, advise
them to use opposite hand to spray to opposite nostril
and to “aim for the ear.”
By Harold J. Farber, MD, MSPH, Associate Professor of Pediatrics,
Pulmonary Section, Baylor College of Medicine and
Texas Children’s Hospital, Associate Medical Director Texas Children’s Health Plan
Affirmative Action Statement
Texas Children’s Health Plan decisions are made on appropriateness of care and service as well as coverage
availability. Texas Children’s Health Plan does not reward practitioners or other staff for issuing denials of
coverage. Financial incentives are not in place relating to Utilization Management decision results.
Texas Children’s Health Plan does not hire, promote, or terminate based on the likelihood that a practitioner
will support or tend to support the denial of benefits.
8
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
Diagnosing and treating Otitis Media:
Update on the new AAP guidelines
The American Academy of Pediatrics convened a committee of primary care physicians and experts in pediatrics,
family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology
to rigorously review the evidence and update their guideline recommendations. The new recommendations were
published online on February 25, 2013
http://pediatrics.aappublications.org/content/early/2013/02/20/peds.2012-3488.
Normal TM.
TM with mild bulging.
TM with moderate bulging.
TM with severe bulging.
Reproduced with permission from Pediatrics, Vol. 131, pages e964 - e999
Key guideline recommendations include:
1. Criteria for diagnosis of otitis media:
a. Should diagnose if: Moderate to severe bulging
of thetympanic membrane (TM) or new onset of
otorrhea not due to acute otitis externa.
2. When to prescribe antibiotics:
a. In children 6 months and older with severe signs
or symptoms (ie., moderate or severe otalgia or
otalgia for at least 48 hours or temperature 39°C
[102.2°F] or higher).
b. In children 6 months through 23 months of age
with bilateral otitis media but without severe signs
or symptoms.
c. Nonsevere unilateral AOM in young children
6 months to 23 months of age without severe
signs or symptoms: Either prescribe antibiotic
therapy or offer observation with close follow-up
based on joint decisionmaking with the
parent(s)/caregiver.
d. Nonsevere AOM in children 24 months and
older: The clinician should either prescribe
antibiotic therapy or offer observation with close
follow-up based on joint decision-making with
the parent(s)/caregiver.
3. What antibiotic to prescribe:
a. Amoxicillin if the child has not received
amoxicillin in the past 30 days AND the child
does not have concurrent purulent conjunctivitis
AND the child is not allergic to penicillin. Most
patients should fit this category.
b. Antibiotic with additional β-lactamase coverage
(such as amoxicillin/clavulinic acid or Cefdinir)
for AOM when the child has received amoxicillin
in the last 30 days OR has concurrent purulent
conjunctivitis, OR has a history of recurrent AOM
unresponsive to amoxicillin.
i. Note that cefixime (Suprax) is NOT
recommended for otitis media due to its poor
anti-pneumococcal activity.
4. No role for prophylactic antibiotics:
a. Clinicians should NOT prescribe prophylactic
antibiotics in children with recurrent AOM.
5. Other things that can help:
a. Influenza Vaccination and Pneumococcal
vaccination as per ACIP vaccination schedules.
b. Breast feeding for at least the first 6 months of life.
c. Eliminate tobacco and other smoke exposure. For
free help with tobacco dependence treatment,
smokers can call the state quitline at
1-800 QUIT- NOW (operated by the American
Cancer Society). Parent education materials in
English and Spanish from the CEASE program can
be downloaded from
www2.massgeneral.org/ceasetobacco.
By Harold J. Farber, MD, MSPH and Sheldon L. Kaplan, MD
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
9
You asked. We listened! New Referral Line
form now available
Texas Children’s Health Plan takes your requests and
suggestions very seriously. We have received a number
of requests for a Referral Line form.
Great news! We developed one for you to use with
your patients.
The Case Management Referral Form is to be used
for patients who require additional medical attention
through our disease management program. If you
have a patient who is a member of Texas Children’s
Health Plan and is in need of case management,
simply fill out the form and fax it to us. We will refer
your patient to the appropriate case manager. You can
find the new form at
www.TexasChildrensHealthPlan.org/For-Providers/
Resources/Downloadable-Forms
If you have questions about the appropriate use of the
form and where to send it, please call your provider
relations manager at 832-828-1008.
Out-of-Network Referrals
All providers are expected to refer to Texas Children’s
Health Plan contracted network providers. We use
in-network providers for services. Referrals to out-ofnetwork providers require authorization and will be
considered for the following reasons:
Continuity of care — the out-of-network provider has
been seeing the member through another health plan
and has a plan of treatment in progress.
Geographic location — the requesting out-of-network
provider is the only provider within the service area.
Specialist care — The requesting out-of-network
provider is the only specialist who can provide the
service within the service area.
10
Emergency care — ER visit and stabilization do
not require authorization. The claim is paid either
in-network, or out-of-network. No request for
emergent services will be retrospectively denied.
If the request for out-of-network services is an initial
start up of care for the member and the services can be
provided by an in-network provider, the services will
be deny and directed to an in-network provider.
The member will be referred to Texas Children’s
Health Plan member services who will assist the
member in setting up an appointment with an
in-network provider.
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
For Your Office Staff
Paper claim submission tips
1. For HCFA claims the NPI and TPI must be
included in box 24J, if you do not include those
two items your claim will be returned to you
for re-submission.
2.Align the print so codes appear within the
designated box. If you print off center then it is
possible your code will be misread and your claim
not paid correctly.
3.If you populate box 32 you must include address
and NPI information in order for the claim to
be complete.
4.Double check diagnosis pointers.
5.Use the RED forms for faster processing.
Following these simple tips will ensure Texas Children’s Health Plan has the clean claim needed to process
your claim quickly and with the least possibility of delays or errors.
Availability of Criteria to Practitioners
It is the policy of Texas Children’s Health Plan to use written criteria based on clinical evidence for appropriate case
application in adjunct to a review of individual circumstances and local health system structure when determining
medical appropriateness of health care services. Criteria used in making a determination will be made available
upon request.
Texas Children’s Health Plan has written decision-making criteria that are objective and based on Medical evidence.
This includes:
InterQual Level of Care Criteria, McKesson,
Acute Care Pediatric
Managing Physical/Occupational/Speech Therapy and
Rehabilitation Care Manual, Sixth Edition, 2008
InterQual Level of Care Criteria, McKesson,
Acute Care Adult
DSM-IV-TR, American Psychiatric Association,
Fourth Edition, 2005
InterQual Care Planning Criteria, McKesson,
Pediatric Procedures
Texas Medicaid Provider Procedures Manual,
Current Year
InterQual Care Planning Criteria, McKesson,
Adult Procedures
Adult Texas Recommended Assessment Guideline (TRAG)
InterQual Level of Care Criteria, McKesson,
Outpatient Rehabilitation & Chiropractic,
Adult & Pediatric
Resiliency and Disease Management Manual, Texas
Department of State Health Services, Community Mental
Health and Substance Abuse Service, March 18, 2010.
InterQual Molecular Diagnostics Criteria, McKesson
American Society of Addiction Medicine Treatment
Guidelines (ASAM), 1999
InterQual Behavior Health Level of Care
Criteria, McKesson
Texas Health and Human Services Commission Medicaid
Providers Manual
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527
11
For Your Office Staff
2012 Member Satisfaction Results
Beginning in 2007, Analytica was commissioned by
Texas Children’s Health Plan to conduct 5,000 interviews
annually with a stratified random sample of members
regarding their satisfaction with their care. This year our
methodology has changed, we conducted 8000 interviews
including 150 high volume providers and we replaced
the 5 point scale with a 0-10 rating scale to align with
the National Committee for Quality Assurance (NCQA)
standards. This report presents the results from 2012 and
compares those results to 2010 and 2011 combined, the
years in which the same active, high volume physician’s
panels were interviewed.
Of the 3 overall measures were statistically significant.
• Th
e doctor‘s care average went up from 9.25 in
2010-2011 to 9.43 in 2012, P=.000.
• Th
e care from staff and office went up from 8.92 to
9.09, P=.000.
• Th
e average for likelihood of recommending went
down (2010-20111- 9.30 to 2012 -9.22, P=.002).
Examination of the performance measures reveals that
survey questions related to the doctor receive higher
ratings; questions relating to waiting time and return
of phone calls receive the lowest ratings. Another item
that stands out because of its relatively lower performance
was the courtesy and friendliness of the receptionist.
The item having the greatest impact on a physician’s
performance was office waiting room time, followed
by exam room waiting time. Next in order of
importance was courtesy and friendliness of receptionist.
Member Satisfaction surveys for 2013 will survey those
physicians last surveyed in 2012. If you or your office
staff would like to have additional training, your Provider
Relations Representative is available to do office staff
presentations on “Through the Patient’s Eyes,” a
customer focused presentation.
To learn more call Provider and Care Coordination at
832-818-1008 or 1-800-731-8527.
12
Provider News
Provider News is published quarterly by
Texas Children’s Health Plan.
© 2013 Texas Children’s Health Plan
All rights reserved.
P.O. Box 301011, NB 8301
Summer 2013
www.TexasChildrensHealthPlan.org • 832-828-1008 • 1-800-731-8527