PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
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<strong>Sendero</strong> Provider Manual Page 2 of 184<br />
5.0 – BEHAVIORAL HEALTH SERVICES .......................................................................... 38<br />
5.1 Definition of Behavioral <strong>Health</strong>...................................................................................................................... 38<br />
5.2 Primary Care Provider Requirements for Behavioral <strong>Health</strong> ......................................................................... 38<br />
5.3 <strong>Sendero</strong> Behavioral <strong>Health</strong> Services Program ................................................................................................ 38<br />
5.4 <strong>Sendero</strong>’s 24-hour/7 Days a Week Behavioral <strong>Health</strong> Crisis Hotline ........................................................... 40<br />
5.5 Covered Behavioral <strong>Health</strong> Services .............................................................................................................. 40<br />
5.6 Referral Authorizations for Behavioral <strong>Health</strong> Services ................................................................................ 41<br />
5.7 Pre-authorization ............................................................................................................................................. 41<br />
5.8 Triage and Initial Assessment ......................................................................................................................... 41<br />
5.9 Concurrent Review ......................................................................................................................................... 42<br />
5.10 Retrospective Review ................................................................................................................................... 42<br />
5.11 Case Management ......................................................................................................................................... 42<br />
5.12 Utilization Decisions ..................................................................................................................................... 43<br />
5.13 Responsibilities of Behavioral <strong>Health</strong> Providers .......................................................................................... 43<br />
5.14 7 Day Follow-up After Inpatient Behavioral <strong>Health</strong> Admission .................................................................. 44<br />
5.15 DSM-IV Coding Requirements .................................................................................................................... 44<br />
5.16 Laboratory Services for Behavioral <strong>Health</strong> Providers .................................................................................. 44<br />
5.17 Court-ordered Services and Commitments ................................................................................................... 45<br />
5.18 Confidentiality of Behavioral <strong>Health</strong> Information ........................................................................................ 45<br />
6.0 – MEDICAL MANAGEMENT .......................................................................................... 46<br />
6.1 Utilization Management Program ................................................................................................................... 46<br />
6.2 Management of Utilization ............................................................................................................................. 46<br />
6.3 Referrals .......................................................................................................................................................... 48<br />
6.4 Pre-Authorization ............................................................................................................................................ 50<br />
6.5 Vision Services ............................................................................................................................................... 52<br />
6.6 Emergency Prescription Supply ...................................................................................................................... 52<br />
6.7 Chiropractic Services ...................................................................................................................................... 52<br />
6.8 Transplant Services ......................................................................................................................................... 52<br />
6.9 Case Management Program ............................................................................................................................ 53<br />
6.10 Disease Management Programs .................................................................................................................... 54<br />
6.11 Practice Guidelines ...................................................................................................................................... 54<br />
7.0 – BILLING AND CLAIMS ................................................................................................. 55<br />
7.1 What is a Claim? ............................................................................................................................................. 55<br />
7.2 What is a Clean Claim?................................................................................................................................... 55<br />
7.3 Electronic Claims Submission: ANSI-837 ..................................................................................................... 55<br />
7.4 Submitting Paper Claims to <strong>Sendero</strong> .............................................................................................................. 55<br />
7.5 Timeliness of Billing....................................................................................................................................... 56<br />
7.6 Timeliness of Payment .................................................................................................................................... 56<br />
7.7 Coding Requirements: ICD9 and CPT/HCPCS Codes ................................................................................... 57<br />
7.8 E&M Office Visits Billing Requirements....................................................................................................... 57<br />
7.9 E&M Consult Billing Requirements ............................................................................................................... 58<br />
7.10 Emergency Services Claims ......................................................................................................................... 58<br />
7.11 Use of Modifier 25 ........................................................................................................................................ 58<br />
7.12 Billing for Assistant Surgeon Services ......................................................................................................... 59<br />
<strong>Sendero</strong> Customer Services 1-855-526-7388 Network Management 1-855-895-0475<br />
<strong>Health</strong> Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)