PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 108 of 184 CH2 – Covered Services CH 2.1 Medically Necessary Services What does medically necessary mean? Covered services for CHIP Members must meet the CHIP definition of "Medically Necessary." "Medically Necessary" means: 1. Physical Health Care Services that are: a. reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a Member, or endanger life; b. provided at appropriate facilities and at the appropriate levels of care for the treatment of Member’s health conditions; c. consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies; d. consistent with the diagnoses of the conditions; e. no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; f. not experimental or investigational; and g. not primarily for the convenience of the Member or Provider. 2. Behavioral Health Services that are: a. reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder; b. provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; c. not experimental or investigative; and d. not primarily for the convenience of the Member or Provider. 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 109 of 184 CH 2.2 CHIP Covered Services Type of Benefit Description of Benefit Limitations Co-Pay Inpatient General Acute and Inpatient Rehabilitation Hospital Services Services include: • Hospital - given doctor or provider services • Semi-private room and board (or private if medically necessary as certified by attending) • General nursing care • Special duty nursing when medically necessary • ICU and services • Patient meals and special diets • Operating, recovery and other treatment rooms • Anesthesia and administration(facility technical component) • Surgical dressings, trays, casts, splints • Drugs, medications and biologicals • blood or blood products not given free-ofcharge to the patient and their administration • X-rays, imaging and other radiological tests (facility technical component) • Laboratory and pathology services (facility technical component) • Machine diagnostic tests (EEGs, EKGs, etc.) • Oxygen services and inhalation therapy • Radiation and chemotherapy • Access to DSHS-designated Level III perinatal centers or hospitals meeting equivalent levels of care • In-network or out-of-network facility and Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section. • Hospital, doctor and related medical services, such as anesthesia, associated with dental care • Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provider administered medications; - ultrasounds; and - histological examination of tissue samples. • Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: - cleft lip and/or palate; or - severe traumatic skeletal and/or congenital craniofacial deviations; or • Requires Notification for non-emergency care and following stabilization of an emergency condition • Requires authorization for out-of-network facility and doctors services as well as for a mother and her newborn(s) after 48 hours following an uncomplicated vaginal delivery and after 96 hours following an uncomplicated delivery by caesarian section Applicable level of inpatient co-pay applies 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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