PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 154 of 184 Mental Health Targeted Case Management Individuals served through the Texas Department of State Health Services (DSHS) Mental Health and Substance Abuse (MHSA) program are eligible for services including advocacy, assessment, linkage, monitoring, crisis intervention, and referral and planning and coordination of services. Priority population include: substance abuse, mental retardation, autism, pervasive development disorder, children at risk of removal from preferred environment, children determined by the school system to have a serious emotional disturbance, children at risk of disruption of the preferred living situation due to psychological symptoms or those with a functional impairment – GAF (Global Assessment Function) of 50 or below. Providers may obtain information through the MHSA website: www.dshs.state.tx.us/MHSA or by contacting Network Management. Texas Department of Assistive and Rehabilitative Services (DARS) DARS may provide additional case management services for the blind and visually impaired Members. This is limited to one contact per client, per month. The main office in Austin may be contacted at 1-800-252-5204 or by visiting their website at http://www.dars.state.tx.us/dbs/. Tuberculosis Services Provided by DSHS Approved Provider All confirmed or suspected cases of Tuberculosis must be referred to the Infectious Disease Control Unit of the DSHS using the forms and procedures for reporting TB adopted by DSHS. Sendero will assist providers in referring to the Local Tuberculosis Control Health Authority within 1 day of diagnosis for a contact investigation. The provider must document the referral to the local health authority in the Member’s medical records that may be reviewed by DSHS and the local authority. Providers should notify Sendero on any referral made to the local health authority. Sendero must coordinate with the local health authority to ensure that Members with confirmed or suspected TB have a contact investigation and receive directly observed therapy. Sendero will report any Member who is non-compliant, drug-resistant, or who is or may be posing a health threat to DSHS or the local authority. Sendero will cooperate with the local health authority in enforcing the control measures and quarantine procedures contained in Chapter 81 of the Health and Safety Code. DADS Hospice Services The Department of Aging and Disability Services (DADS) manages the Hospice Program through provider enrollment contracts with hospice agencies. Coverage of services follow the amount duration and scope of services specified in the Medicare Hospice Program. Hospice pays for services related to the treatment of the client’s terminal illness and for certain physician services (not the treatments). Hospice care includes medical and support services designed to keep clients comfortable and without pain during the last weeks and months before death. CP 2.7 Pharmacy/Navitus The CHIP Perinatal newborn’s prescriptions and the CHIP Perinatal mother’s prenatal vitamins are covered by the CHIP Perinatal. Sendero Health Plans has an arrangement with Navitus Health Solutions, a pharmacy benefit management company to administer pharmacy benefits for the CHIP Perinatal. For questions related to the formulary, preferred drug list, prescription over-rides, quantity limits, brand necessity or formulary 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 155 of 184 exceptions, please contact Navitus at 877-908-6023 or access the Navitus website through www.senderohealth.com. The only drugs eligible for are listed in the current Texas listing of National Drug Codes. Sendero will assist its Members with medication management through the primary care providers and/or Specialists. NAVITUS SUPPORTS E-PRESCRIBING FOR MEDICAID D ME • Navitus provides point of care information available through Surescripts • Eligibility confirmation Daily updates to eligibility facilitator • Medication history • Formulary and PDL benefit confirmation • Formulary “alternative” drug list • Formulary lists will be updated no less frequently than weekly • Navitus expects pharmacies to have ability to accept e-prescriptions and facilitate refills with prescribers Navitus will encourage Texas Medicaid Network Pharmacies to become Medicaid-enrolled durable medical equipment (DME) providers with the MCO’s in their Service Areas. CP 2.8 Co-Pay Information for CHIP Perinatal Members There are no co-payments for CHIP Perinatal Members or CHIP Perinatal Newborn Members. CP 2.9 OB/GYN Sendero allows you to pick an OB/GYN but this doctor must be in the same network as your Primary Care Provider. ATTENTION FEMALE MEMBERS You have the right to pick an OB/GYN without a referral from your Primary Care Provider. An OB/GYN can give you care related to your current pregnancy 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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