PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
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<strong>Sendero</strong> Provider Manual Page 115 of 184<br />
Type of Benefit Description of Benefit Limitations Co-Pay<br />
Outpatient Substance<br />
Abuse Treatment<br />
Services<br />
Rehabilitation Services<br />
Outpatient substance abuse treatment services<br />
include, but are not limited to:<br />
• Prevention and intervention services that are<br />
offered by doctor and non-doctor providers,<br />
such as screening, assessment and referral for<br />
chemical dependency disorders.<br />
• Intensive outpatient services<br />
• Partial hospitalization<br />
• Intensive outpatient services is defined as an<br />
organized non-residential service providing<br />
structured group and individual therapy,<br />
educational services, and life skills training that<br />
consists of at least 10 hours per week for four to<br />
12 weeks, but less than 24 hours per day.<br />
• Outpatient treatment service is defined as<br />
consisting of at least one to two hours per week<br />
providing structured group and individual<br />
therapy, educational services, and life skills<br />
training.<br />
Habilitation (the act of supplying a child with the<br />
means to reach age-appropriate developmental<br />
milestones through therapy or treatment) and<br />
rehabilitation services include, but are not limited to,<br />
the following:<br />
• Physical, occupational and speech therapy<br />
• Developmental assessment<br />
• Does not require prior<br />
authorization for the first 20<br />
visits, then pre authorization<br />
is required.<br />
• Does not require Primary<br />
• Outpatient treatment services<br />
up to a maximum of:<br />
• Intensive outpatient program<br />
(up to 12 weeks per 12-<br />
month period).<br />
• Outpatient services (up to<br />
six-months per 12-month<br />
period)<br />
Requires pre-authorization after<br />
the 8 th visit and a physician’s<br />
prescription<br />
Applicable level of copay<br />
applies to office<br />
visits.<br />
Co-pays do not apply<br />
Hospice Care Services<br />
Services include, but are not limited to:<br />
• Palliative care, including medical and support<br />
services, for children who have six months or<br />
less to live, to keep patients comfortable during<br />
the last weeks and months before death<br />
• Treatment services, including treatment related<br />
to the terminal illness, are unaffected by<br />
electing hospice care services.<br />
• Requires notification only<br />
• Services apply to the hospice<br />
diagnosis<br />
• Up to a maximum of 120<br />
days with a 6 month life<br />
expectancy<br />
• Patients electing hospice<br />
services may cancel this<br />
election at anytime<br />
Co-pays do not apply<br />
<strong>Sendero</strong> Customer Services 1-855-526-7388 Network Management 1-855-895-0475<br />
<strong>Health</strong> Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)