PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 24 of 184
Event
A Member’s Travel
Requirements to Reach a
Primary Care Provider or
General Hospital
A Member’s Travel
Requirements To Secure An
Initial Contact With A Referral
Specialist, Specialty Hospital,
Psychiatric Hospital, Or
Diagnostic And Therapeutic
Services
Wait Times
Requirement
A Member is not required to travel in excess of thirty (30)
miles to reach a primary care provider or general hospital.
A Member is not required to travel in excess of seventyfive
(75) miles to secure an initial contact with a referral
specialist, specialty hospital, psychiatric hospital, or
diagnostic and therapeutic services (if one is available).
Members should not wait longer than 45 minutes in the
office waiting room prior to being taken to the examination
room. Members should not wait more than 15 minutes to
be seen by a provider after being taken to an examination
room.
3.8 Primary Care Provider Referrals to Other Providers
Primary Care Provider Referrals to Network Providers
The Sendero PCP to In-Network Specialist Referral / Authorization Form or the Texas Authorization/Referral
Form (see Appendix A of this manual) should be filled out and given to the Member when referring the
Member to specialists or other ancillary providers for medically necessary services within the Sendero Health
Plans’ network. You should explain to the member that the specialist may not see the member without this
form. The member needs to give this form to the specialist so that the specialist knows that the member is being
referred by you, why the member is being referred, what the expectations are for the visit, and how many visits
are being allowed.
Primary Care Provider Referrals to Non-network Providers
In rare situations, the primary care provider may believe that the most medically appropriate referral for a
specific Member with a unique medical condition is to a non-network provider. Referral to non-network
providers must be referred to the Health Services department for review and pre-authorization. Health Services
must be given a written justification stating member specific reasons for Out-Of-Network care. For preauthorization
of a non-network referral, the primary care provider must contact the Health Services Department
by calling 1-855-297-9191, faxing a request to 512-275-2862, or complete an online referral on the
SenderoHealth.com provider portal. Once the request for Out-of-Network care is received, it will be reviewed
by Sendero’s Medical Director and sent to Network Management.
3.9 Members Right to Self-Referral
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)