PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 156 of 184 CP3 – Well Child Exams Well Child Exams are for children’s health checkups. These checkups are important and Members should set up an appointment with their primary care provider within 45 days of becoming a Sendero Member. Even if a child looks and feels well, he or she may still have a problem Well Child Exams can help in many ways. Some of the things done in a medical checkup are: Physical exam, measuring height and weight; Hearing and eye check; Checking for a good diet; Immunizations (when needed); Blood tests (when needed) TB test CP 3.1 Periodicity Schedule and Immunization Requirements Providers are required to follow the periodicity schedule as defined by the American Academy of Pediatrics (AAP) and/or the Centers for Disease Control and Prevention. Providers are required to participate with the Texas Vaccines for Children Program (TVFC). CP 3.2 Texas Vaccines for Children (TVFC) Program The Texas Vaccines for Children Program provides free vaccines to CHIP members who are younger than 19 years of age that are routinely recommended according to the American Academy of Pediatrics (AAP) immunization schedule. To obtain free vaccine, the provider must enroll in the TVFC program through Department of State Health Services (DSHS). There is no reimbursement to providers for vaccines available from TVFC although reimbursement is available for the administration of the vaccines. For more information, contact DSHS at 800-252-9152 or 512-776-7284or Network Management at phone number below. 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 157 of 184 CP4 – Complaints & Appeals CP 4.1 Introduction Sendero has established procedures for handling and resolving 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 Department before going to a state agency. CP 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. CP 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. CP 4.4 CHIP Perinatal: 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)
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PROVIDER MANUAL - Sendero Health Plans

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