PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 21 of 184
circumstances for Significant Traditional Providers or providers who have functioned long term in a
field that is appropriate for the diagnosis of the Member with special health care needs.)
2. The Specialist must have admitting privileges at a network hospital.
3. The Specialist must agree to be the primary care provider for the Member. He/she will be contacted and
informed of the Member’s selection. The Specialist must then sign the Specialist as a PCP Referral
form (available by calling Network Management) for the Member with special needs that has made the
request.
4. The Specialist must agree to abide by all the requirements and regulations that govern a primary care
provider, including but not limited to:
a. being available 24 hours a day, 7 days a week,
b. administering immunizations as required, and
c. acting as the medical home and coordinating care for this Member
The effective date of the Specialist functioning as the Member’s primary care provider will be the first of the
month following the date the Specialist as a PCP Referral form is signed by the Medical Director. The effective
date of the designation of the specialist as the member’s PCP may not be applied retroactively. Sendero will not
reduce the amount of compensation owed to the original primary care physician for services provided before the
date of the new designation.
3.5 Primary Care Provider Panel of Members
Open Panel of Members
Sendero desires all primary care providers to maintain an open panel and accept new Members that may select
the primary care provider for medical care. Sendero understands that, from time to time, a primary care
provider’s panel will become full and necessitate the primary care provider to close his or her panel.
Closing Primary Care Provider Panel of Members
Primary care providers must notify Sendero’s Network Management representative in writing if the primary
care provider’s panel needs to be closed. The primary care provider’s written notice should include an
explanation of why his/her panel needs to be closed. Sendero requests that primary care providers provide at
least 30 days’ notice of the closure of their panel. Once the panel is closed, Sendero will not allow the primary
care provider to selectively accept new Members unless the Member or siblings of the Member were existing
Members of the primary care provider.
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)