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 128 of 184<br />
CH4 – Complaints & Appeals<br />
CH 4.1 Introduction<br />
<strong>Sendero</strong> <strong>Health</strong> <strong>Plans</strong> has established procedures for the handling and resolution of complaints and appeals. If a<br />
provider or Member is not satisfied with the resolution of a complaint, an appeal can be filed. <strong>Sendero</strong><br />
Customer Services is available to assist those persons requiring assistance with the filing of a complaint or<br />
appeal. It is <strong>Sendero</strong>’s goal to resolve all complaints. A Member or provider may initiate the complaint process<br />
either by telephone, in person, or in writing, expressing the details of the concerns. Providers may submit<br />
complaints to <strong>Sendero</strong> or to the Texas Department of Insurance. <strong>Sendero</strong> would prefer that complaints come to<br />
the <strong>Sendero</strong> Quality Improvement team before going to a state agency.<br />
CH 4.2 What is a Complaint?<br />
A complaint is a verbal or written expression of dissatisfaction with <strong>Sendero</strong> <strong>Health</strong> <strong>Plans</strong> concerning a process<br />
within the health plan. A complaint is not a misunderstanding or misinformation that is resolved promptly by<br />
supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the provider. It<br />
is anticipated that the majority of the verbal and written complaints would be resolved with <strong>Sendero</strong>.<br />
CH 4.3 What is an Appeal?<br />
There are three (3) types of appeals. They are:<br />
Complaint Appeal is an appeal that occurs when the complainant is not satisfied with the outcome of the<br />
complaint. This is not a medical necessity determination appeal.<br />
Adverse Medical Determination Appeal is an appeal that occurs when there has been a denial of benefit<br />
because of lack of medical necessity.<br />
Expedited Appeal is an appeal at an expedited rate that occurs when the usual timeframe for appeal<br />
response may jeopardize the Member’s health. This expedited appeal may occur for a complaint or an<br />
adverse medical determination appeal.<br />
CH 4.4 CHIP Program: Complaints & Appeals<br />
What should I do if I have a Complaint?<br />
A provider, Member, or someone acting on the behalf of the Member (“Complainant”) may initiate the<br />
complaint process either by telephone, in person, or in writing, expressing the details of the concerns.<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)