PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 159 of 184
• How will I be notified if services are denied?
The Member and provider will be notified of the denial of services within three days of the Sendero Medical
director rendering the decision via a letter. If the denial is a medical necessity denial, the Medical Director
issuing the denial will attempt to contact the requesting provider and discuss the situation with him/her prior
to denying the services. A denial letter is sent out within three (3) days of making the decision.
• Can Someone from Sendero Help Me File an Appeal?
Members needing help with filing the appeal should call Customer Services toll free number at the number
below 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
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 Perinatal Member
A provider, Member or someone acting on behalf of the Member may request an expedited appeal if they
believe the expectant mother, the unborn Member or the newborn’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 to an Independent Review Organization
(IRO), through the Texas Department of Insurance. The process must be initiated by Sendero, so the proper
forms should be completed and submitted to Sendero as soon as possible – a Member Advocate is available to
help the appellant complete the form.
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)