PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 40 of 184 5.4 Sendero’s 24-hour/7 Days a Week Behavioral Health Crisis Hotline Sendero Health Plans subcontracts for a crisis hotline to Avail Solutions, which is available 24 hours a day / 7 days a week at: 1-888-287-5402 for STAR Members 1-888-287-5403 for CHIP Members These numbers are listed on the Member’s ID card. The crisis hotline provides a Crisis Intervention Specialist who is available to screen the needs of the Member and direct the Member for an initial psychiatric or therapist evaluation. An authorization is not required for initial evaluation. Once a Member is seen, it is the responsibility of the contracted provider to fax a completed Texas Referral Authorization Form (Attachment A) to the Primary Care Physician The following circumstances indicate that a referral to a physician is recommended: The Member is receiving psychoactive medication for an emotional or behavioral problem or condition. The Member has significant medical problems that impact his/her emotional well-being. The Member is having suicidal and/or homicidal ideations. The Member has delirium, amnesia, a cognitive disorder, or other condition for which there is a probable medical (organic) etiology. The Member has a substance use disorder such as substance-induced psychosis, substance induced mood disorder, substance induced sleep disorder, etc. The Member has or is likely to have a psychotic disorder, major depression, bipolar disorder, panic disorder, or eating disorder. The Member is experiencing severe symptoms or severe impairment in level of functioning or has a condition where there is a possibility that a pharmacological intervention will significantly improve the Member’s condition. The Member has another condition where there is a significant possibility that somatic treatment would be of help. Conditions include dysthymia, anxiety, adjustment disorders, post-traumatic stress disorders, and intermittent explosive disorders. The Member has a substance abuse problem. 5.5 Covered Behavioral Health Services The following services are available to all STAR and CHIP Members: Inpatient Substance Abuse Treatment Services Outpatient Substance Abuse Treatment Services 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 41 of 184 The following services are available to all STAR Members under the age of 21 years of age and to all CHIP members: Inpatient Mental Health Services Outpatient Mental Health Services Behavioral Health Inpatient Facilities must ensure that a seven (7) day follow-up appointment is made prior to Member discharge from an inpatient stay. For details about behavioral health covered benefits see “ST2 STAR/Medicaid Covered Services” or “CH2 Covered Services” in this manual. 5.6 Referral Authorizations for Behavioral Health Services Sendero Members do not require referrals from their primary care providers for initial evaluation or follow-up behavioral health treatment from an in network Behavioral Health provider. Pre-authorization is only required for Psychological testing. . Primary care providers may provide Behavioral Health Services for Members, if it is within the scope of his/her practice. . 5.7 Pre-authorization Prior authorization is required for > 20 visits for outpatient treatments. Prior authorization of an emergent, elective or scheduled admission is NOT required. The Behavioral Health Hotline is available for members 24/7 by calling Avail Solutions at 1-888-287-5402 for STAR and 1-888-287-5403 for CHIP. Psychological testing requires pre-authorization. This may be obtained by the provider faxing a prior-authorization for psychological testing form to the Health Services Department for approval prior to testing being initiated. (See the fax number at the bottom of this page.) 5.8 Triage and Initial Assessment Sendero has clinicians available 24 hours a day, seven days a week to help Members with referrals to practitioners, facilities, urgent or emergent care and crisis calls. Sendero’s RN Care Coordinators or a Crisis Intervention Specialist (through the Behavioral Health Crisis Hotline) helps Members with clinical determinations, urgent and emergent care, crisis calls and referrals to facilities. The goal of the referral and triage process is to provide accurate information and referrals to appropriate providers. During the workday, call Sendero’s RN Care Coordinators at 1-855-297-9191 for assistance. After hours, on weekends and on holidays, a Crisis Intervention Specialist can be reached at: 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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