PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 14 of 184 HMS – providing Coordination of Benefits OptiCare – will provide Sendero’s members with services for their Vision benefits 2.5 Role of Primary Care Provider The primary care provider is the cornerstone for Sendero Health Plans. The primary care provider serves as the “Medical Home” for the Member. The “Medical Home” concept should help in establishing a relationship between the patient and provider, and ultimately better health outcomes. The primary care provider is responsible for the provision of all primary care services for the Sendero STAR, CHIP, and CHIP Perinatal Members. In addition, the primary care provider is responsible for facilitating referrals and authorization for specialty services to Sendero network providers, as needed. For more information on the responsibilities of the primary care provider, see “3.0 Guidelines for Providers” in this manual. 2.6 Role of the Specialty Care Provider The Specialty Care provider collaborates with the primary care provider to deliver specialty care to STAR, CHIP, and CHIP Perinatal Members. A key component of the Specialist’s responsibility is to maintain ongoing communication with the Member’s primary care provider. Specialty providers are responsible to ensure necessary referrals/authorizations have been obtained prior to provision of services. For more information on the responsibilities of the Specialty Care provider, see “3.0 Guidelines for Providers” in this manual. 2.7 Role of the CHIP Perinatal Provider The CHIP Perinatal provider establishes a relationship with the expectant mother in order to provide services to the unborn member to promote a healthy pregnancy and delivery. The Perinatal provider renders services such as prenatal visits, assessments, planning services, education and counseling along with coordination of routine prenatal laboratory testing. The CHIP Perinatal provider also prescribes medications to promote healthy pregnancy and provides attending services during hospitalization related to the delivery of the unborn child. 2.8 Role of the Pharmacy The role of Navitus, the chosen pharmacy option for Sendero, is to provide an effective network of sites and pharmacy providers to provide access for members and providing prescription fulfillment while improving health and providing superior customer service in a manner that instills trust and confidence to Sendero 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 15 of 184 members. Navitus and the PBM industry will be fully compliant and converted to NCPDP E.1 electronic eligibility verification by January 1, 2012 2.9 Network Limitations (e.g. Primary Care Providers, Specialists, OB/GYN) Members are limited to the use of providers that are contracted with Sendero Health Plans. Exceptions can be made temporarily when continuity of care would be disrupted if the Member did not continue with an out-ofnetwork provider. All out-of-network referrals must be approved by the Health Services department. For more information on referrals to out-of-network providers, see “3.0 Guidelines for Providers” below. Members who are involved in an “active course of treatment” have the option of completing that course of treatment with their current provider regardless of whether the current provider is contracted with Sendero or terminates their contract with Sendero during the treatment phase. This option applies to Members who: Have pre-existing conditions Are in their 3 rd trimester of pregnancy Are receiving care for an Acute medical condition Are receiving care for an Acute episode of a chronic condition Are receiving care for a life threatening illness, or Are receiving care for a disability Members who fall into these categories will work with a Sendero Nurse Care Coordinator to transition services when it is appropriate to do so over a reasonable period of time as determined by the individual member’s situation. To contact a Nurse Care Coordinator, call Health Services at 1-855-297-9191. 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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