PROVIDER MANUAL - Sendero Health Plans

More documents

Recommendations

Info

Sendero Provider Manual Page 32 of 184 Ability to utilize community resources (churches, community based organizations, self-help groups, school programs) Ability to provide therapeutic and pharmacological interventions, with an understanding of the cultural differences in treatment expectations and biological response to medication. Ability to ask for consultation. ATTITUDES demonstrating cultural sensitivity: Respect the "survival merits" of immigrants and refugees. Respect the importance of cultural forces. Respect the holistic view of health and illness. Respect the importance of spiritual beliefs. Respect and appreciate the skills and contributions of other professional and paraprofessional disciplines. Be aware of transference and counter transference issues. 3.17 Reporting Fraud, Waste, or Abuse by a Provider or Member For information regarding reporting Fraud, Waste or Abuse, see “10.0 – Fraud, Waste or Abuse” in this Manual. 3.18 Termination of Provider Participation Provider-requested Termination As outlined in each provider’s contract, a provider retains the right to terminate his/her participation in the Sendero network for any reason. If a provider desires to terminate his/her service agreement with Sendero, a written notice to Sendero is required either ninety (90) days prior to the desired effective date of the termination or in accordance with the time frames outlined in the provider’s contract with Sendero. Sendero will honor requests for termination, but may work with the provider to see if some other alternative can be identified to prevent network termination. In the event of a conflict between this rule and the provider’s contract, the contract will prevail. Sendero -requested Termination Sendero will follow the procedures outlined in §843.306 of the Texas Insurance Code if terminating a contract with you as a provider. At least 30 days before the effective date of the proposed termination of your contract, Sendero will provide a written explanation to you indicating the reasons for termination. Sendero may immediately terminate a provider contract if the provider presents imminent harm to Member health, actions against a license or practice, fraud or malfeasance. 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 33 of 184 Within 60 days of the termination notice date, you may request a review of Sendero’s proposed termination by an advisory review panel, except in a case in which there is imminent harm to Member health, an action against a private license, fraud or malfeasance. The advisory review panel will be composed of physicians and roviders, as those terms are defined in §843.306 Texas Insurance Code, including at least one representative in your specialty or a similar specialty, if available, appointed to serve on Sendero’s Quality Improvement Committee or Provider Advisory Subcommittee. The decision of the advisory review panel must be considered by Sendero but is not binding on Sendero. Sendero must present to you, on request, a copy of the recommendation of the advisory review panel and Sendero’s determination. According to your agreement with Sendero Health Plans, you are entitled to sixty (60) days advance written notice of our intent to terminate your agreement for cause. The agreement also states that it will terminate immediately and without notice under certain circumstances. If we give you a sixty (60) day notice of intended termination or if your agreement terminates immediately without notice, and the cause for termination is based on concerns regarding competence or professional conduct as the result of formal peer review, you may appeal the action pursuant to this procedure. This procedure is available only if we are terminating your agreement for the reasons stated above. You may not offer or give anything of value to an officer or employee of HHSC or the State of Texas in violation of state law. A “thing of value” means any item of tangible or intangible property that has a monetary value of more than $50.00 and includes, but is not limited to, cash, food, lodging, entertainment and charitable contributions. The term does not include contributions to public office holders or candidates for public office that are paid and reported in accordance with state and/or federal law. Sendero may terminate this Network Provider contract at any time for violation of this requirement. Notice of Proposed Action Sendero Health Plans will give you notice that your agreement has terminated or is about to terminate, and the reason(s) for the termination. The notice will either accompany your sixty (60) day notice of termination, or be given at the time your agreement terminates immediately without notice. Upon termination of your agreement with Sendero, you may request reinstatement by special notice (registered or certified mail) within thirty (30) days of receiving the notice of termination to Sendero’s Medical Director. You should include any explanation or other information with your request for reinstatement. Sendero’s Medical Director will appoint a committee to review your request, and any information or explanation provided within thirty (30) days of receipt. The committee will recommend an initial decision to the Sendero Board of Directors to reaffirm your agreement, reaffirm with sanctions, or to revoke your contract as a Sendero network provider. Decision Within ten (10) days of receiving the committee’s recommendations, Sendero will, by special notice in registered or certified mail, inform you of our decision on your request for reinstatement. This decision will be final. Sendero will work with Members currently receiving care from you to transition to other providers within the Sendero network pursuant to the Transition of Care policy. This transition will occur based on the individual 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)
Page 1 and 2: Sendero Provider Manual Page 1 of 1
Page 11 and 12: Sendero Provider Manual Page 11 of
Page 31: Sendero Provider Manual Page 31 of
Page 83 and 84:
Sendero Provider Manual Page 83 of
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
show all

PROVIDER MANUAL - Sendero Health Plans

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?