PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 160 of 184 Sendero will make every effort to honor the Appellant’s request for an expedited appeal. If the rationale for request does not meet the definition of an expedited appeal (decision warranted quickly due to the Member’s critical health outcome), Sendero may deny the request to expedite the review. If this happens, the provider may intervene on the Member’s behalf and discuss the situation with the Medical Director. The provider should contact the Medical Director by calling Health Services at the number shown at the bottom of this page. In the event the request for the appeal to be expedited does not meet criteria to be expedited, the appeal will be processed within the standard appeal process timeframes. Independent Review Organization Appeal through TDI for CHIP Members CHIP Perinatal Members may request an appeal directly to an Independent Review Organization (IRO) through the Texas Department of Insurance (TDI). An IRO is an outside organization assigned by TDI to review the health plan’s denial of services. Direct appeals to the IRO are available for those cases that involve a life-threatening disease or condition for which the likelihood of death is probable if the course of treatment for the disease or condition is interrupted. In addition, CHIP Members have the right to request an IRO for non-life threatening disease or conditions after exhausting Sendero’s internal appeal process. Sendero must initiate this process. To request an IRO, the Appellant should contact Health Services at the phone number at the bottom of the page. Sendero will provide the Appellant with the necessary forms that must be completed and returned to Sendero. Sendero will send the request to TDI, who will appoint the IRO to review the case within one (1) business day of receipt of the request. TDI will notify the Appellant and Sendero who was appointed as the IRO. Sendero will then submit all required documentation to the IRO within three (3) business days. The IRO will make a decision within five (5) days from the date they receive the information from Sendero for life threatening situations, or within fifteen (15) days for non-life threatening situations. Decisions of the IRO are final and binding. Sendero will abide by the decision of the IRO, and will incur all expenses of the IRO review. 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 161 of 184 CP5 – CHIP Perinatal Member Rights and Responsibilities CP 5.1 Member Rights 1. You have a right to get accurate, easy-to-understand information to help you make good choices about your unborn child’s health plan, doctors, hospitals and other providers. 2. You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work. 3. You have a right to know how the health plan decides whether a Perinatal service is covered and/or medically necessary. You have the right to know about the people in the health plan who decides those things. 4. You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses. 5. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed. 6. You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan. 7. You have the right and responsibility to take part in all the choices about your unborn child’s health care. 8. You have the right to speak for your unborn child in all treatment choices. 9. You have the right to be treated fairly by the health plan, doctors, hospitals and other providers. 10. You have the right to talk to you Perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records. 11. You have the right to a fair and quick process for solving problems with the health plan and the plan's doctors, hospitals and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right. CP 5.2 Member Responsibilities You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities: 1. You must try to follow healthy habits. Stay away from tobacco and alcohol and eat a healthy diet. 2. You must become involved in the doctor's decisions about your unborn child’s care. 3. If you have a disagreement with the health plan, you must try first to resolve it using the health plan's complaint process. 4. You must learn about what your health plan does and does not cover. Read your CHIP Perinatal Handbook to understand how the rules work. 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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