PROVIDER MANUAL - Sendero Health Plans

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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)
Sendero Provider Manual Page 37 of 184 4.6 Emergency Dental Services Medical Emergency Dental Services: Sendero is responsible for emergency dental services provided to Medicaid Members in a hospital or ambulatory surgical center setting. We will pay for devices for craniofacial anomalies, hospital, physician, and related medical services (e.g. anesthesia and drugs) for: treatment of a dislocated jaw, traumatic damage to teeth, and removal of cysts; treatment of oral abscess of tooth or gum origin; and treatment craniofacial anomalies CHIP Emergency Dental Services: Sendero is responsible for emergency dental services provided to CHIP Members and CHIP Perinate Newborn Members in a hospital or ambulatory surgical center setting. We will pay for devices for craniofacial anomalies, hospital, physician, and related medical services (e.g. anesthesia and drugs) for: treatment of a dislocated jaw, traumatic damage to teeth, and removal of cysts; treatment of oral abscess of tooth or gum origin; and treatment craniofacial anomalies 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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