PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 36 of 184
4.2 Prudent Layperson Standards at Sendero
Sendero Health Plans’ standards regarding Prudent Layperson comply with the Texas Administrative Code
definition for emergency services. See definition of Emergent Care above.
4.3 Out of Network Emergency Services
Out of network emergency services are covered by Sendero. Any services rendered are reimbursed at the usual
and customary rate. Members who must use emergency services while out of the service area are encouraged to
contact their primary care provider as soon as possible and advise them of the emergent situation.
4.4 Emergency Transportation
Emergency transportation, such as ambulance service, is covered by Sendero. Emergency transportation is
defined as transportation to an acute care facility, when there is a life and death situation. Ambulance service
companies are to submit claims to Sendero for reimbursement.
4.5 Emergency Services Outside the Service Area
If a Member is injured or becomes ill while temporarily outside of the service area, the Member should contact
his / her primary care provider and follow his / her or the covering physician’s instructions, unless the condition
is life-threatening. If the condition is life-threatening, as determined by a prudent layperson, the Member may
go to the nearest emergency facility. The Member should notify Sendero of the incident within 48 business
hours (or the primary care provider should notify the Sendero within 24 hours or the next business day) after
learning of the out-of-area emergency. An authorization number will be issued based on medical criteria, for
inpatient services. Emergency room services do not require authorization. If the Member is admitted to an outof-area
hospital, the Sendero Health Services Department, in conjunction with the primary care provider, will
monitor the Member’s condition with the out-of-area attending physician. Sendero will help the primary care
provider in arranging for follow up care upon the member’s return to the service area when medically
appropriate.
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)