PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 22 of 184 3.6 Primary Care Provider Panel Changes Primary Care Provider Changes Members have a right to change primary care providers up to three (3) times a year, but may receive Sendero authorization for a more frequent change as deemed necessary by Sendero. Sendero closely monitors primary care provider changes because such changes may disrupt the continuity of care and/or may indicate Member dissatisfaction with aspects of their care. Sendero will make every attempt to address a Member’s concerns prior to their making a primary care provider change and may even contact the primary care provider for help in resolving the Member’s issue if dissatisfaction with the current primary care provider is the cause for the Member requesting a primary care provider change. If a Member requests to change primary care providers on or before the 5 th of the month, the change will be retroactive to the first of the month. After the 5 th of the month, the change will be effective on the first of the following month. The change of primary care provider will be expedited if the change is determined by Sendero to be in the best interest of the Member and/or the current primary care provider. Sendero reserves the right to reassign a Member’s primary care provider or close a provider’s panel if, in Sendero’s sole determination, it is in the best interest of the Member. Primary Care Provider-requested Removal of a Member from Panel Primary care providers may request the removal of a Member from their panel in select situations. Sendero will work to resolve problems between the Member and the primary care provider before making the change. The following may be reasons for a primary care provider to request that a Member be removed from his/her panel: Member is consistently non-compliant with the primary care provider’s medical advice Member is consistently disruptive in the office Member consistently misses scheduled appointments without cause and/or without notice to the office 3.7 Primary Care Provider & Specialist Accessibility and Appointment Standards Accessibility Standards Primary care providers and Specialists serving as a primary care provider for certain Members must be available to Members 24 hours a day, 7 days a week. Your office is expected to answer phone calls during your routine office hours with after-hours telephone availability or arrangements as follows: o Access to covering physician, or o Answering service, or o Triage service, or o A voice message in English and Spanish that provides a second phone number that is answered or returned within 30 minutes of the Member leaving a message. 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 23 of 184 Appointment Standards Primary care providers, Specialists serving as a primary care provider for certain Members, and Specialists must make appointments available to Members as follows: Event Requirement Emergency Services Emergency Services must be provided upon Member presentation at the service delivery site, including at nonnetwork and out-of-area facilities; Urgent Care, including Urgent Urgent care, including urgent specialty care must be Specialty Care provided within 24 hours of request; Routine Primary Care Routine primary care must be provided within 14 days of request; Initial Outpatient Behavioral Initial outpatient behavioral health visits must be provided Health Visits within 14 days of request; Outpatient Behavioral Health Behavioral Health outpatient treatment must occur within 7 Treatment following a days from the date of discharge following an inpatient Behavioral Health Inpatient Behavioral Health stay. Admission Routine Specialty Care Referrals Routine specialty care referrals must be provided within 30 days of request; Initial Prenatal Visits Prenatal care must be provided within 14 days of request, except for high-risk pregnancies or new Members in the third trimester, for whom an appointment must be offered within five days or immediately, if an emergency exists; Preventive Health Services for Initial outpatient visits must be provided within 14 days of Adults request; Preventive Health Services for Preventive health services for children, including wellchild checkups should be offered to Members in Children, including Well-Child Checkups accordance with the American Academy of Pediatrics (AAP) periodicity schedule. Sendero follows the Texas Health Steps Program modifications to the AAP periodicity schedule. For newly enrolled Members under age 21, overdue or upcoming well-child checkups, including Texas Health Steps medical checkups, should be offered as soon as practicable, but in no case later than 14 days of enrollment for newborns, and no later than 60 days Member Access to Primary Care Provider of enrollment for all other eligible child Members. Members are able to reach their primary care provider twenty-four (24) hours a day, seven (7) days a week, either by answering service or by coverage of another physician. Primary care provider (or covering physician) should call the Member within 30 minutes of the Member contacting the answering service. 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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