PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 124 of 184 Tuberculosis Services Provided by DSHS Approved Provider All confirmed or suspected cases of Tuberculosis must be referred to the Infectious Disease Control Unit of the DSHS using the forms and procedures for reporting TB adopted by DSHS. Sendero will assist providers in referring to the Local Tuberculosis Control Health Authority within 1 day of diagnosis for a contact investigation. The provider must document the referral to the local health authority in the Member’s medical records that may be reviewed by DSHS and the local authority. Providers should notify Sendero on any referral made to the local health authority. Sendero must coordinate with the local health authority to ensure that Members with confirmed or suspected TB have a contact investigation and receive directly observed therapy. Sendero will report any Member who is non-compliant, drug-resistant, or who is or may be posing a health threat to DSHS or the local authority. Sendero will cooperate with the local health authority in enforcing the control measures and quarantine procedures contained in Chapter 81 of the Health and Safety Code. DADS Hospice Services The Department of Aging and Disability Services (DADS) manages the Hospice Program through provider enrollment contracts with hospice agencies. Coverage of services follow the amount duration and scope of services specified in the Medicare Hospice Program. Hospice pays for services related to the treatment of the client’s terminal illness and for certain physician services (not the treatments). Hospice care includes medical and support services designed to keep clients comfortable and without pain during the last weeks and months before death. CH 2.7 Pharmacy/Navitus Sendero Health Plans has an arrangement with Navitus Health Solutions, a pharmacy benefit management company to administer pharmacy benefits for the STAR program. For questions related to the formulary, preferred drug list, prescription over-rides, quantity limits, brand necessity or formulary exceptions, please contact Navitus at 877-908-6023 or access the Navitus website through www.senderohealth.com. NAVITUS SUPPORTS E-PRESCRIBING FOR MEDICAID • Navitus provides point of care information available through Surescripts • Eligibility confirmation Daily updates to eligibility facilitator • Medication history • Formulary and PDL benefit confirmation • Formulary “alternative” drug list • Formulary lists will be updated no less frequently than weekly • Navitus expects pharmacies to have ability to accept e-prescriptions and facilitate refills with prescribers 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 125 of 184 D ME Navitus will encourage Texas Medicaid Network Pharmacies to become Medicaid-enrolled durable medical equipment (DME) providers with the MCO’s in their Service Areas. CH 2.8 Co-Pay Information for CHIP Members The following table lists the CHIP co-payment schedule according to family income. No co-payments are paid for preventive care such as well-child or well-baby visits or immunizations. The Sendero CHIP Member ID card lists the co-payments that apply to the Member. The Member must present this ID card when the Member receives services from your office. You are required to collect the co-pay as part of the office visit. Federal Poverty Levels Native Americans At or Below 100% Office Visits Emergency Room Visits Inpatient Hospitalizations Prescription Generic Drugs Prescription Brand Drugs $0 $0 $0 $0 $0 $0 $3 $3 $10 $0 $3 101%-150% $5 $5 $25 $0 $5 151%-185% $12 $50 $50 $8 $25 186%-200% $16 $50 $100 $8 $25 Once a Year Reporting Caps 1.25% cap of family yearly income 1.25% cap of family yearly income 2.5% cap of family yearly net income 2.5% cap of family yearly net income CH 2.9 OB/GYN Sendero allows you to pick an OB/GYN but this doctor must be in the same network as your Primary Care Provider. ATTENTION FEMALE MEMBERS You have the right to pick an OB/GYN without a referral from your Primary Care Provider. An OB/GYN can give you: 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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