PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 2 of 184 5.0 – BEHAVIORAL HEALTH SERVICES .......................................................................... 38 5.1 Definition of Behavioral Health...................................................................................................................... 38 5.2 Primary Care Provider Requirements for Behavioral Health ......................................................................... 38 5.3 Sendero Behavioral Health Services Program ................................................................................................ 38 5.4 Sendero’s 24-hour/7 Days a Week Behavioral Health Crisis Hotline ........................................................... 40 5.5 Covered Behavioral Health Services .............................................................................................................. 40 5.6 Referral Authorizations for Behavioral Health Services ................................................................................ 41 5.7 Pre-authorization ............................................................................................................................................. 41 5.8 Triage and Initial Assessment ......................................................................................................................... 41 5.9 Concurrent Review ......................................................................................................................................... 42 5.10 Retrospective Review ................................................................................................................................... 42 5.11 Case Management ......................................................................................................................................... 42 5.12 Utilization Decisions ..................................................................................................................................... 43 5.13 Responsibilities of Behavioral Health Providers .......................................................................................... 43 5.14 7 Day Follow-up After Inpatient Behavioral Health Admission .................................................................. 44 5.15 DSM-IV Coding Requirements .................................................................................................................... 44 5.16 Laboratory Services for Behavioral Health Providers .................................................................................. 44 5.17 Court-ordered Services and Commitments ................................................................................................... 45 5.18 Confidentiality of Behavioral Health Information ........................................................................................ 45 6.0 – MEDICAL MANAGEMENT .......................................................................................... 46 6.1 Utilization Management Program ................................................................................................................... 46 6.2 Management of Utilization ............................................................................................................................. 46 6.3 Referrals .......................................................................................................................................................... 48 6.4 Pre-Authorization ............................................................................................................................................ 50 6.5 Vision Services ............................................................................................................................................... 52 6.6 Emergency Prescription Supply ...................................................................................................................... 52 6.7 Chiropractic Services ...................................................................................................................................... 52 6.8 Transplant Services ......................................................................................................................................... 52 6.9 Case Management Program ............................................................................................................................ 53 6.10 Disease Management Programs .................................................................................................................... 54 6.11 Practice Guidelines ...................................................................................................................................... 54 7.0 – BILLING AND CLAIMS ................................................................................................. 55 7.1 What is a Claim? ............................................................................................................................................. 55 7.2 What is a Clean Claim?................................................................................................................................... 55 7.3 Electronic Claims Submission: ANSI-837 ..................................................................................................... 55 7.4 Submitting Paper Claims to Sendero .............................................................................................................. 55 7.5 Timeliness of Billing....................................................................................................................................... 56 7.6 Timeliness of Payment .................................................................................................................................... 56 7.7 Coding Requirements: ICD9 and CPT/HCPCS Codes ................................................................................... 57 7.8 E&M Office Visits Billing Requirements....................................................................................................... 57 7.9 E&M Consult Billing Requirements ............................................................................................................... 58 7.10 Emergency Services Claims ......................................................................................................................... 58 7.11 Use of Modifier 25 ........................................................................................................................................ 58 7.12 Billing for Assistant Surgeon Services ......................................................................................................... 59 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 3 of 184 7.13 Billing for Capitated Services ....................................................................................................................... 59 7.14 Billing for Immunization and Vaccine Services ........................................................................................... 59 7.15 Billing for Texas Health Steps (Medicaid STAR only) or Well Child Visit Services ................................. 59 7.16 Billing for Deliveries and Newborn Services ............................................................................................... 60 7.17 Billing for Outpatient Surgery Services ........................................................................................................ 60 7.18 Billing for Hospital Observation Services .................................................................................................... 61 7.19 Coordination of Benefits (COB) Requirements ............................................................................................ 61 7.20 Billing Members ........................................................................................................................................... 61 7.21 Collecting from or Billing CHIP Members for Co-pay Amounts ................................................................ 62 7.22 Billing Members for Non-covered Services ................................................................................................. 63 7.23 Providers Required to Report Credit Balances ............................................................................................. 63 7.24 Filing an Appeal for Non-payment of a Claim ............................................................................................. 63 7.25 Claims & Appeals Questions ........................................................................................................................ 64 7.26 Electronic Funds Transfer (EFT) .................................................................................................................. 64 8.0 – SENDERO QUALITY PROGRAM ................................................................................ 65 8.1 Sendero’s Quality Improvement Program (QIP) ............................................................................................ 65 8.2 Sendero’s Provider Quality Measures ............................................................................................................ 65 8.3 Sendero’s HEDIS ® Measurements ................................................................................................................. 66 8.4 Sendero’s Quality Improvement Committee .................................................................................................. 66 8.5 How to Get Involved in Sendero’s Quality Program ...................................................................................... 66 8.6 Provider Report Cards..................................................................................................................................... 67 8.7 Confidentiality ................................................................................................................................................ 67 8.8 Focused Studies and Utilization Management reporting requirements .......................................................... 68 9.0 – CREDENTIALING AND RE-CREDENTIALING ....................................................... 69 9.1 Credentialing and Re-credentialing Oversight................................................................................................ 69 9.2 Provider Site Reviews ..................................................................................................................................... 69 9.3 Required Office Policies & Procedures .......................................................................................................... 70 9.4 Re-Credentialing Requirements ...................................................................................................................... 71 10.0 – FRAUD, WASTE OR ABUSE ....................................................................................... 72 TEXAS STAR PROGRAM ....................................................................................................... 74 ST1 – ELIGIBILITY OF MEMBERS ..................................................................................... 75 ST 1.1 HHSC Determines Eligibility ................................................................................................................... 75 ST 1.2 Role of Enrollment Broker ........................................................................................................................ 75 ST 1.3 General Eligibility for STAR/Medicaid .................................................................................................... 75 ST 1.4 Span of Eligibility (Members’ Right to Change Health Plans) ................................................................. 76 ST 1.5 Disenrollment from Health Plan ............................................................................................................... 76 ST2 – STAR/MEDICAID COVERED SERVICES ................................................................ 77 ST 2.1 STAR/Medicaid Managed Care Covered Services ................................................................................... 77 ST 2.2 Sendero’s Value Added Services .............................................................................................................. 81 ST 2.3 Family Planning Services .......................................................................................................................... 82 ST 2.4 Non-Urgent Medical Transportation Services .......................................................................................... 83 ST 2.5 Coordination with Non-Medicaid Managed Care Covered Services: ....................................................... 83 ST 2.6 Pharmacy/Navitus ..................................................................................................................................... 86 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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