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 23 of 184<br />
Appointment Standards<br />
Primary care providers, Specialists serving as a primary care provider for certain Members, and Specialists must<br />
make appointments available to Members as follows:<br />
Event<br />
Requirement<br />
Emergency Services<br />
Emergency Services must be provided upon Member<br />
presentation at the service delivery site, including at nonnetwork<br />
and out-of-area facilities;<br />
Urgent Care, including Urgent Urgent care, including urgent specialty care must be<br />
Specialty Care<br />
provided within 24 hours of request;<br />
Routine Primary Care<br />
Routine primary care must be provided within 14 days of<br />
request;<br />
Initial Outpatient Behavioral Initial outpatient behavioral health visits must be provided<br />
<strong>Health</strong> Visits<br />
within 14 days of request;<br />
Outpatient Behavioral <strong>Health</strong> Behavioral <strong>Health</strong> outpatient treatment must occur within 7<br />
Treatment following a<br />
days from the date of discharge following an inpatient<br />
Behavioral <strong>Health</strong> Inpatient Behavioral <strong>Health</strong> stay.<br />
Admission<br />
Routine Specialty Care Referrals Routine specialty care referrals must be provided within 30<br />
days of request;<br />
Initial Prenatal Visits<br />
Prenatal care must be provided within 14 days of request,<br />
except for high-risk pregnancies or new Members in the<br />
third trimester, for whom an appointment must be offered<br />
within five days or immediately, if an emergency exists;<br />
Preventive <strong>Health</strong> Services for Initial outpatient visits must be provided within 14 days of<br />
Adults<br />
request;<br />
Preventive <strong>Health</strong> Services for Preventive health services for children, including wellchild<br />
checkups should be offered to Members in<br />
Children, including Well-Child<br />
Checkups<br />
accordance with the American Academy of Pediatrics<br />
(AAP) periodicity schedule. <strong>Sendero</strong> follows the Texas<br />
<strong>Health</strong> Steps Program modifications to the AAP<br />
periodicity schedule. For newly enrolled Members under<br />
age 21, overdue or upcoming well-child checkups,<br />
including Texas <strong>Health</strong> Steps medical checkups, should be<br />
offered as soon as practicable, but in no case later than 14<br />
days of enrollment for newborns, and no later than 60 days<br />
Member Access to Primary Care<br />
Provider<br />
of enrollment for all other eligible child Members.<br />
Members are able to reach their primary care provider<br />
twenty-four (24) hours a day, seven (7) days a week, either<br />
by answering service or by coverage of another physician.<br />
Primary care provider (or covering physician) should call<br />
the Member within 30 minutes of the Member contacting<br />
the answering service.<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)