PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 34 of 184 termination situation (upon completion of the Notice of Action process, your appeal or immediately) depending on the reasons for termination of the contract.. 3.19 Member Materials From time to time, Sendero sends various communications to Members. These materials are produced at or below the 6 th grade reading level to ensure that they can be understood by all Members regardless of their educational level. Providers are encouraged to make available Member notices and general information about their practice in a similar form to ensure that Members understand the information. This does not apply to health education materials that are provided to Members. 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 35 of 184 4.0 – Emergency Services 4.1 Definitions: Routine, Urgent and Emergent Services Routine Routine care is defined as health care for covered preventive and medically necessary Health Care Services that are non-emergent or non-urgent, such as a well child visit, a chronic condition status visit or an annual physical examination. Urgent Care Urgent care is defined as when a Member needs to be seen, evaluated and treated within 24 hours. An urgent need may be for illness or injury that is non-life threatening. Emergent Care Emergency care is defined as health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, serious disfigurement, or in the case of a pregnant woman, serious jeopardy to the health of the fetus. “Emergency services” and “emergency care” means health care services provided in an in-network or out-ofnetwork hospital emergency department or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize medical conditions. Emergency services also include, but are not limited to, any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an emergency condition exists. Some conditions that may require taking the Member to the Emergency Room include: Incessant infant crying Excessive, uncontrolled bleeding Epiglottitis High fever Pneumonia Loss of consciousness Kidney stones Referral from primary care provider to ER (regardless of diagnosis) Mental Health conditions where the Member is a threat to themselves or others Fracture Severe laceration Status asthmatic Urinary tract infection, pyelonephritis Concussion Loss of respiration Convulsions Poisoning Overdose situations Severe abdominal pain Chest pain 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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