PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 150 of 184 SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS For Members who could be sustained on an age-appropriate diet. Traditionally used for infant feeding In pudding form (except for people with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care given by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a doctor and used to give care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Able to get coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Able to get coverage for person with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Able to get coverage for person with diabetes. Med Ejector X Needles and See Diabetic Supplies Syringes/Diabetic Needles and See IV Therapy and Dressing Supplies/Central Line. Syringes/IV and Central Line Needles and Syringes/Other X Able to get coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Stump Sleeve Stump Socks Suction Catheters Syringes X X X See Needles/Syringes. 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 151 of 184 SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the Primary Care Provider and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When decided to be medically necessary. Urostomy supplies See Ostomy Supplies. CP 2.5 Sendero’s Value Added Service In addition to the benefits included in the CHIP Perinatal, Sendero provides certain value added services for Members. The Sendero value added services are: Value Added Service Nurse Line Extra Help with Getting a Ride CHIP Perinatal NEWBORN Program SERVICE: Sendero will make available to the caregivers of CHIP Perinatal Newborn Members a 24 hour a day, 365 days per year nurse advice line. Caregivers will be able to access the nurse line via a toll-free telephone number. The nurse line will be able to assist the Caregiver with various health-related questions, as well as provide guidance as to when to access emergency facilities for the newborn member. SERVICE: Sendero will help arrange transportation to physician appointments for the Perinatal Newborn beyond those services covered by the MTP program LIMITATIONS: plan reserves the right to determine medical necessity In addition to the benefits for the CHIP Perinatal Member (unborn child), Sendero provides certain value added services for mother of the unborn Member. The Sendero value added services are: Value Added Service Nurse Line CHIP Perinatal SERVICE: Sendero will make available to CHIP Perinatal expectant mothers a 24 hour a day, 365 days per year nurse advice line. Members will be able to access the nurse line via a toll-free telephone number. The nurse line will be able to assist Members with various health-related questions, as well as provide guidance as to when to access emergency facilities. 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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