PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 114 of 184 Type of Benefit Description of Benefit Limitations Co-Pay Outpatient Mental Health Services Inpatient Substance Abuse Treatment Services Mental health services, including for serious mental illness, provided on an outpatient basis, including but not limited to: • The visits can be furnished in a variety of community-based settings (including school and home-based) or in a state-operated facility. • Medication management • Rehabilitative day treatments • Residential treatment services • Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment) • Skills training (psycho-educational skill development) Inpatient substance abuse treatment services include, but are not limited to inpatient and residential substance abuse treatment services including detoxification, crisis stabilization, and 24-hour residential rehabilitation programs. • Does not require prior authorization for the first 20 visits, then pre-authorization is required. • Does not require Primary Care Provider referral. • Neuropsychological and psychological testing DO require Prior Authorization • When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. • A Qualified Mental Health Professional – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1), §412.303(48). QMHP-CSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or doctor and provides services in accordance with DSHS standards. Those services include individual and group skills training (that can be components of interventions such as day treatment and inhome services), patient and family education, and crisis services. • Does not require prior authorization. • Does not require Primary Care Provider referral. Applicable level of copay applies to office visits. 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)
Sendero Provider Manual Page 115 of 184 Type of Benefit Description of Benefit Limitations Co-Pay Outpatient Substance Abuse Treatment Services Rehabilitation Services Outpatient substance abuse treatment services include, but are not limited to: • Prevention and intervention services that are offered by doctor and non-doctor providers, such as screening, assessment and referral for chemical dependency disorders. • Intensive outpatient services • Partial hospitalization • Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training that consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day. • Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training. Habilitation (the act of supplying a child with the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to, the following: • Physical, occupational and speech therapy • Developmental assessment • Does not require prior authorization for the first 20 visits, then pre authorization is required. • Does not require Primary • Outpatient treatment services up to a maximum of: • Intensive outpatient program (up to 12 weeks per 12- month period). • Outpatient services (up to six-months per 12-month period) Requires pre-authorization after the 8 th visit and a physician’s prescription Applicable level of copay applies to office visits. Co-pays do not apply Hospice Care Services Services include, but are not limited to: • Palliative care, including medical and support services, for children who have six months or less to live, to keep patients comfortable during the last weeks and months before death • Treatment services, including treatment related to the terminal illness, are unaffected by electing hospice care services. • Requires notification only • Services apply to the hospice diagnosis • Up to a maximum of 120 days with a 6 month life expectancy • Patients electing hospice services may cancel this election at anytime Co-pays do not apply 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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