PROVIDER MANUAL - Sendero Health Plans

More documents

Recommendations

Info

Sendero Provider Manual Page 106 of 184 Pregnant Members are no longer automatically dis-enrolled from CHIP and placed in Medicaid. Health plans notify the enrollment broker when a CHIP Member is pregnant and a re-determination for Medicaid eligibility occurs. This process can take up to an average of 60 days, and Member ID card may not be available from plan, immediately. There is no spell of illness limitation for CHIP Members. CH 1.4 Span of Eligibility (Members’ Right to Change Health Plans) - CHIP Members are allowed to make health plan changes under the following circumstances: For any reason within the first ninety (90) days of enrollment in CHIP For cause at any time During the annual re-enrollment period Requests are forwarded to HHSC, who makes the final determination. For more information, contact the CHIP Helpline at 1-800-647-6558. CH 1.5 Disenrollment from Health Plan Disenrollment may occur if a Member loses CHIP eligibility. A CHIP Member can lose CHIP eligibility for the following reasons: “Aging-out” when the Member turns 19 Failure to re-enroll by the end of the 12 month coverage period Change in health insurance status, i.e., a Member enrolls in an employer sponsored health plan Death of a Member Member permanently moves out of the state Failure to drop current insurance if child was determined to be CHIP eligible because cost sharing under the current health plan totaled 10% or more of the family’s gross income Child’s parent or authorized representative requests, in writing, the voluntary disenrollment of a child Providers may not request that a Member be disenrolled from the health plan, and from managed care, without good cause. The provider cannot make this request due to retaliatory action against the Member. Sendero can also request a Member be disenrolled from Sendero for the following reasons: Fraud or intentional material misrepresentation Fraud in the use of services or facilities Misconduct that is detrimental to safe plan operations and the delivery of services Sendero Customer Services 1-855-526-7388 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)
Sendero Provider Manual Page 107 of 184 Failure to establish a satisfactory patient/physician or patient/provider relationship Child no longer lives or resides in the service area Sendero cannot request a disenrollment based on adverse change in the Member’s health status or utilization of services that are medically necessary for the treatment of a Member’s condition. All requests are forwarded to HHSC, who makes the final decision. CH 1.6 Pregnancy Notification Requirements – CHIP If a provider identifies a CHIP Member as being pregnant, he/she should notify Health Services Department immediately so as to ensure that the Member receives the highest level of coverage available. Many pregnant CHIP teenagers and their newborns, up to age one year, will qualify for Medicaid. Since the Medicaid Program now provides a much more comprehensive scope of services for both the pregnant teen and their newborn, it is in the best interest of the pregnant teen to receive Medicaid coverage as early as possible. For this reason, it is critical that providers notify Sendero immediately upon learning about a CHIP teenager’s pregnancy. Sendero will notify the HHSC that the CHIP Member is pregnant. Pregnant CHIP teenagers who are Medicaid eligible will be transferred from CHIP to Medicaid by HHSC. For CHIP Members who are not Medicaid eligible, Sendero will be responsible to cover the costs of the delivery; however, the provider must immediately notify Sendero about the delivery. Newborns of CHIP Members do not automatically become CHIP Members. Upon notification by the provider, Sendero will refer the newborn to Medicaid to determine eligibility. Newborns deemed not eligible for Medicaid, will be enrolled in CHIP as determined by HHSC. Providers are encouraged to submit a Pregnancy Notification Form to Sendero, so that we are apprised of this pregnant Member, and can get the Member enrolled in High Risk OB Case Management as appropriate. Sendero Customer Services 1-855-526-7388 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)
Page 1 and 2:
Sendero Provider Manual Page 1 of 1
Page 3 and 4:
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Sendero Provider Manual Page 11 of
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56: Sendero Provider Manual Page 55 of
Page 105: Sendero Provider Manual Page 105 of
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
show all

PROVIDER MANUAL - Sendero Health Plans

Create successful ePaper yourself

Delete template?

Save as template?