PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 128 of 184 CH4 – Complaints & Appeals CH 4.1 Introduction Sendero Health Plans has established procedures for the handling and resolution of complaints and appeals. If a provider or Member is not satisfied with the resolution of a complaint, an appeal can be filed. Sendero Customer Services is available to assist those persons requiring assistance with the filing of a complaint or appeal. It is Sendero’s goal to resolve all complaints. A Member or provider may initiate the complaint process either by telephone, in person, or in writing, expressing the details of the concerns. Providers may submit complaints to Sendero or to the Texas Department of Insurance. Sendero would prefer that complaints come to the Sendero Quality Improvement team before going to a state agency. CH 4.2 What is a Complaint? A complaint is a verbal or written expression of dissatisfaction with Sendero Health Plans concerning a process within the health plan. A complaint is not a misunderstanding or misinformation that is resolved promptly by supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the provider. It is anticipated that the majority of the verbal and written complaints would be resolved with Sendero. CH 4.3 What is an Appeal? There are three (3) types of appeals. They are: Complaint Appeal is an appeal that occurs when the complainant is not satisfied with the outcome of the complaint. This is not a medical necessity determination appeal. Adverse Medical Determination Appeal is an appeal that occurs when there has been a denial of benefit because of lack of medical necessity. Expedited Appeal is an appeal at an expedited rate that occurs when the usual timeframe for appeal response may jeopardize the Member’s health. This expedited appeal may occur for a complaint or an adverse medical determination appeal. CH 4.4 CHIP Program: Complaints & Appeals What should I do if I have a Complaint? A provider, Member, or someone acting on the behalf of the Member (“Complainant”) may initiate the complaint process either by telephone, in person, or in writing, expressing the details of the concerns. 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 129 of 184 Who do I call? To initiate by telephone, the Complainant should call Customer Service at the number shown at the bottom of this page. The customer service representative will try to resolve the issue immediately. If the issue cannot be resolved during this phone call, the CSR will help the Complainant complete the Complaint Form and will route the issue to the appropriate department. Can someone from Sendero help me file a Complaint? If the Complainant needs help with filing the complaint, they should request this when calling Customer Services. Someone within SENDERO will help the complainant. (CHIP Members may call Customer Services at 1-877-451-5598 or 694-6780 to file a complaint.) If a complaint is verbal (i.e. by telephone or in person), the Sendero representative receiving the initial communication will request that the complainant submit the complaint in writing, when possible. A Sendero Complaint Form will be sent to the complainant. The Sendero Complaint Form can be found in Appendix A of this Manual. The mailing address and fax number where complaints may be directed is as follows: Sendero Health Plans ATTN: Member Advocate Suite 510 2028 E. Ben White Blvd. Austin, TX, 78741 Fax Number – 512.275.2862 How long will it take to process my Complaint? A written acknowledgement will be sent within five (5) business days, confirming receipt of the complaint. Sendero will resolve all complaints within thirty (30) calendar days from receipt of complaint. The Complainant will be sent a complaint resolution letter summarizing the results of the issue presented and setting out the complaint appeal process and timeframes for appeal. If I am not satisfied with the outcome, who else can I contact? (How to file a Complaint Appeal) If the Complainant is not satisfied with the complaint resolution, an appeal may be filed. An appeal must be filed within thirty (30) days of the date on the resolution letter. The resolution letter will provide information regarding the right to appeal before a Complaint Appeal Panel. In addition to appealing the response to Sendero, the Complainant has the right to contact the Texas Department of Insurance by calling 1-800-252- 3439, or write them at P.O. Box 149104, Austin, Texas 78714-9104, if he/she is not satisfied with Sendero’s resolution. CHIP Member Appeal Process for Denial of Services CHIP Members have the right to appeal when services are denied. Listed below are common questions and procedure that will provide information regarding this appeal process. 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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