PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 130 of 184
• What can I do if Sendero denies or limits my patient’s request for a covered service?
If the Member, provider, or someone acting on behalf of the Member, is denied a request for a covered
service by Sendero, they may file an appeal to Sendero. (See the process below for filing an Appeal of
Adverse Determination.)
• How will I be notified if services are denied?
If the requested service is not able to be approved due to lack of medical necessity, the Medical Director
will attempt to contact the requesting provider and discuss the situation with him/her prior to denying the
service(s). A denial letter is sent out within three (3) days of the Medical Director making his/her coverage
decision.
• Can Someone from Sendero Help Me File an Appeal?
Members needing help with filing the appeal should call Customer Services toll free number and request
this help. A Member Advocate will be available to help the Member. This includes help with filing an
Expedited Appeal.
Appeal of Adverse Determination for CHIP Member
If the Sendero Medical Director determines that requested services do not meet medical necessity criteria, then
coverage for medical services may be denied. The provider, Member or someone acting on behalf of the
Member (“Appellant”) is entitled to request the appeal process through Sendero Health Plans. The denial letter
sent to the provider and Member will outline the process, along with the appropriate forms, to initiate the
appeal. An appeal may be submitted orally or in writing. If the appeal is submitted orally, an appeal form will
be sent with the acknowledgement letter for the Appellant to complete and return to Sendero. Appellant must
submit the appeal in writing, signed by the Member or Member’s representative.
An acknowledgement letter will be sent to the Appellant within five (5) days of receipt of the appeal. The
appeal will be reviewed by a Medical Director or physician designee who did not participate in the original
denial and a decision will be rendered within thirty (30) days of receipt of the appeal. The decision letter will
include the rationale for the decision, the name of the Specialist provider that may have helped in the decision,
whether the denial has been overturned, partially overturned or upheld. If partially overturned or upheld, the
appellant will receive information regarding the second level appeal process to have the issue reviewed by an
Independent Review Organization. Appellant may request help with filing the 2 nd level appeal by contacting
Customer Services at the phone number at the bottom of this page.
Expedited Appeal for CHIP Member
A provider, Member or someone acting on behalf of the Member may request an expedited appeal if they
believe the Member’s life or health could be jeopardized by the time frames involved in the normal appeal
process. Appellant may file the request orally or in writing. In addition, the Appellant may request help in
filing the appeal. They should contact Customer Services and request the help. Someone within Sendero will
provide that help. During an expedited appeal, a health care provider who has not previously reviewed the case
will review the appeal. The expedited appeal will be completed no later than one (1) working day following the
day on which the appeal, including all information necessary to complete the appeal, is made to Sendero. If the
appeal involves a life-threatening disease or condition for which the likelihood of death is probable if the course
of treatment of the disease or condition is interrupted, the Appellant may request the case be directly forwarded
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)