PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 4 of 184 ST 2.7 OB/GYN.................................................................................................................................................... 87 ST3 – ALBERTO N .................................................................................................................... 88 ST 3.1 Alberto N First Partial Settlement Agreement .......................................................................................... 88 ST 3.2 Alberto N Second Partial Settlement Agreement ...................................................................................... 90 ST4 – TEXAS HEALTH STEPS PROGRAM ........................................................................ 91 ST 4.1 What is the Texas Health Steps Program? ................................................................................................ 91 ST 4.2 How Can I Become a Texas Health Steps Provider? ................................................................................ 91 ST 4.3 Finding a Texas Health Steps Provider ..................................................................................................... 92 ST 4.4 Texas Health Steps Periodicity Schedule .................................................................................................. 92 ST 4.5 Eligibility for Texas Health Steps Exam ................................................................................................... 92 ST 4.6 Timely Texas Health Steps Exam ............................................................................................................. 92 ST 4.7 Exams outside the Texas Health Steps Periodicity Schedule ................................................................... 92 ST 4.8 Texas Health Steps Exams for Newborns ................................................................................................. 93 ST 4.9 Immunization Requirements for Children................................................................................................. 93 ST 4.10 Children of Migrant Farm workers ......................................................................................................... 93 ST 4.11 Texas Vaccines for Children (TVFC) Program ...................................................................................... 94 ST 4.12 Texas Health Steps Lab and Testing Supplies ........................................................................................ 94 ST 4.13 Texas Health Steps Dental Screenings .................................................................................................... 94 ST 4.14 Dental-oral Evaluation and Fluoride Varnish (OEFV) ........................................................................... 94 ST 4.15 Texas Health Steps Vision ...................................................................................................................... 95 ST 4.16 Referral for Services Identified During a Texas Health Steps ............................................................ 95 ST 4.17 Outreach to Members for Texas Health Steps Exams ............................................................................. 95 ST 4.18 Pregnancy Notification Requirements .................................................................................................... 96 ST5 – COMPLAINTS & APPEALS ........................................................................................ 97 ST 5.1 Introduction ............................................................................................................................................... 97 ST 5.2 What is a Complaint? ................................................................................................................................ 97 ST 5.3 What is an Appeal? ................................................................................................................................... 97 ST 5.4 STAR Program: Complaints & Appeals ................................................................................................... 97 ST6 – STAR/MEDICAID MEMBER RIGHTS AND RESPONSIBILITIES ................... 101 ST 6.1 Member Rights ........................................................................................................................................ 101 ST 6.2 Member Responsibilities ......................................................................................................................... 102 TEXAS CHIP PROGRAM ..................................................................................................... 104 CH1 – ELIGIBILITY OF MEMBERS .................................................................................. 105 CH 1.1 HHSC Determines Eligibility ................................................................................................................. 105 CH 1.2 Role of Enrollment Broker ..................................................................................................................... 105 CH 1.3 General Eligibility for CHIP .................................................................................................................. 105 CH 1.4 Span of Eligibility (Members’ Right to Change Health Plans) - CHIP ................................................. 106 CH 1.5 Disenrollment from Health Plan............................................................................................................. 106 CH 1.6 Pregnancy Notification Requirements – CHIP ...................................................................................... 107 CH2 – COVERED SERVICES ............................................................................................... 108 CH 2.1 Medically Necessary Services ................................................................................................................ 108 CH 2.2 CHIP Covered Services .......................................................................................................................... 109 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 5 of 184 CH 2.3 CHIP Member Prescriptions .................................................................................................................. 117 CH 2.4 EXCLUSIONS for CHIP Benefits ......................................................................................................... 117 CH 2.4 DME/SUPPLIES – for CHIP Programs ................................................................................................. 118 CH 2.5 Sendero’s Value Added Services ........................................................................................................... 120 CH 2.6 Coordination with Non-CHIP Covered Services: .................................................................................. 122 CH 2.7 Pharmacy/Navitus .................................................................................................................................. 124 CH 2.8 Co-Pay Information for CHIP Members ................................................................................................ 125 CH 2.9 OB/GYN ................................................................................................................................................. 125 CH3 – WELL CHILD EXAMS .............................................................................................. 127 CH 3.1 What is a Well Child Exam? .................................................................................................................. 127 CH 3.2 Periodicity Schedule and Immunization Requirements ......................................................................... 127 CH 3.3 Texas Vaccines for Children (TVFC) Program ..................................................................................... 127 CH4 – COMPLAINTS & APPEALS ..................................................................................... 128 CH 4.1 Introduction ............................................................................................................................................ 128 CH 4.2 What is a Complaint? ............................................................................................................................. 128 CH 4.3 What is an Appeal?................................................................................................................................. 128 CH 4.4 CHIP Program: Complaints & Appeals ................................................................................................. 128 CH5 – CHIP MEMBER RIGHTS AND RESPONSIBILITIES ......................................... 132 CH 5.1 Member Rights ....................................................................................................................................... 132 CH 5.2 Member Responsibilities ........................................................................................................................ 133 TEXAS CHIP PERINATAL ................................................................................................... 135 CP1 – ELIGIBILITY OF MEMBERS ................................................................................... 136 CP 1.1 HHSC Determines Eligibility ................................................................................................................. 136 CP 1.2 Role of Enrollment Broker ...................................................................................................................... 136 CP 1.3 General Eligibility for CHIP Perinatal .................................................................................................... 136 CP 1.4 Span of Eligibility (Members’ Right to Change Health Plans) – CHIP Perinatal .................................. 137 CP 1.5 Disenrollment from Health Plan ............................................................................................................. 137 CP2 – COVERED SERVICES................................................................................................ 139 CP 2.1 Medically Necessary Services ................................................................................................................ 139 CP 2.2 CHIP Perinatal Covered Services ........................................................................................................... 140 CP 2.3 EXCLUSIONS for CHIP Perinatal Member Benefits ............................................................................ 147 CP 2.4 DME/SUPPLIES – for CHIP Perinatal Newborn Members ................................................................... 148 CP 2.5 Sendero’s Value Added Service ............................................................................................................. 151 CP 2.6 NON-CHIP Perinatal Covered Services (non-Capitated Services) ........................................................ 152 CP 2.7 Pharmacy/Navitus ................................................................................................................................... 154 CP 2.8 Co-Pay Information for CHIP Perinatal Members ................................................................................. 155 CP 2.9 OB/GYN ................................................................................................................................................. 155 CP3 – WELL CHILD EXAMS ............................................................................................... 156 CP 3.1 Periodicity Schedule and Immunization Requirements .......................................................................... 156 CP 3.2 Texas Vaccines for Children (TVFC) Program ...................................................................................... 156 CP4 – COMPLAINTS & APPEALS ...................................................................................... 157 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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