PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 120 of 184 SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS Care care. Irrigation Sets, Urinary X Able to get coverage for person with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Able to get coverage for person with diabetes. Med Ejector X Needles and See Diabetic Supplies Syringes/Diabetic Needles and See IV Therapy and Dressing Supplies/Central Line. Syringes/IV and Central Line Needles and Syringes/Other X Able to get coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Stump Sleeve X Stump Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the Primary Care Provider and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When decided to be medically necessary. Urostomy supplies See Ostomy Supplies. CH 2.5 Sendero’s Value Added Services In addition to the standard benefits for CHIP noted above, Sendero Health Plans provides certain value added services for Members. Sendero’s value added services for Members with CHIP coverage are: 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 121 of 184 Value Added Service Nurse Line Value-added Vision Services Temporary Cell Phone Gifts for New Mothers Sports/School Physicals Extra Help with Getting a Ride Extra Dental Benefits Pregnant Women CHIP Program SERVICE: Sendero will make available to CHIP Members a 24 hour a day, 365 days per year nurse advice line. Members will be able to access the nurse line via a toll-free telephone number. The nurse line will be able to assist Members with various health-related questions, as well as provide guidance as to when to access emergency facilities. SERVICE: $100 above the Medicaid allowable per 24 month period for corrective eyewear. LIMITATION: The benefit is limited only as it applies to frequency and Members who are 2 years or older. SERVICE: Sendero will provide pre-programmed cell phones to pregnant Members who are determined to be high-risk. This service will permit these Members to be in touch on both inbound and outbound call with the Plan’s health Service care coordinator and the PCP/OB in order to ask questions and receive advice, reminded of appointments, arrange for transportation and to contact 911 in case of emergency. LIMITATION: As it applies only to female Members who are determined high-risk and during the pre, peri and immediate post natal period SERVICE: Sendero will provide up to $50 worth of health items for pregnant Members who complete at least eight (8) prenatal visits to their OB during pregnancy. At least 1 gift will be for Member. LIMITATION: As it applies only to pregnant Members and the completion of the minimum required number of eight (8) prenatal appointments while a Member of Sendero. SERVICE: Sendero will reimburse its contracted PCP for an annual sports/school physical for children up to age 19 at the PCP’s contracted rate. LIMITATION: Only limitation is under age 19 SERVICE: Sendero will help arrange transportation to physician appointments beyond those services covered by the MTP program LIMITATIONS: plan reserves the right to determine medical necessity SERVICE: Sendero will pay for up to $250 in dental services each year for pregnant member LIMITATIONS: value limited to $250 and for pregnant members only 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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