PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 181 of 184
Provider Complaints and Appeals
A. Sendero has established the following process for receiving, resolving, tracking and reporting all provider
indications of dissatisfaction.
1. A complaint(s) from a provider is received at Sendero either through telephone contact or through a
written complaint.
a. If the Provider calls into Sendero, he/she will be warm transferred to the Network
Management Manager
b. If a complaint is received in writing, the complaint will be forwarded to the Network
Management Manager
2. All complaints must be submitted in writing. If received telephonically, Sendero will refer the
provider to the Sendero web portal to download the Provider Complaint Form (Attachment A) or
will fax or mail the form to the provider to complete. The complaint will then be logged onto the
Provider Complaint Tracking tool (Attachment B) with the following data elements:
a. The date the Complaint was received;
b. Provider name and NPI number
c. Where the complaint was received
d. Provider phone number
e. Provider name
f. Provider contact person/caller
g. A detailed description of the complaint
B. The Network Management Manager will review each complaint from a provider and investigate the
concerns expressed by the provider. The Network Management Manager will collaborate with department
leadership of units involved in the complaint to establish a resolution for the provider that is consistent with
all applicable regulatory, accrediting and contract statutes.
C. The Network Management Manager will send a written notice to the provider outlining the findings of her
review. The notice to the provider will include the opportunity for and an explanation of how the provider
can pursue a Formal Desk Review through HHSC if he/she is not satisfied with the review outcome within
Sendero. If after completing Sendero’s internal review process, the provider believes they did not receive
full due process, they may file a complaint or inquiry at HPM_complaints@hhsc.state.tx.us or:
Texas Health and Human Services Commission
Provider Complaints
Health Plan Operations, H-320
PO Box 85200
Austin, Texas 78708
D. After the Formal Desk Review, Sendero’s Network Management Manager will send a FDR final
determination notice (Attachment D) to the provider with the outcome of the review noting that the provider
has exhausted all review procedures available through Sendero Health Plans.
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)