PROVIDER MANUAL - Sendero Health Plans

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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)
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PROVIDER MANUAL - Sendero Health Plans

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