PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 42 of 184 24 Hour Behavioral Health Hotline (CHIP) 1-888-287-5403 24 Hour Behavioral Health Hotline (STAR) 1-888-287-5402 5.9 Concurrent Review Sendero’s RN Care Coordinators conduct concurrent review via telephone on all Members admitted to inpatient mental health hospitalizations, inpatient detoxification, chemical dependency rehabilitation, partial hospitalization and intensive outpatient treatment. Concurrent review includes review of medical necessity, discharge planning and researching, and coordinating alternatives to inpatient care. RN Care Coordinators use Milliman Care Guidelines and/or InterQual Criteria to help with all concurrent review determinations. A Medical Director is available to review difficult cases and reviews all potential denials or questionable cases. The purpose of the concurrent review function is to continue coordination of patient care with the treating facility or provider to determine the best course of treatment for the Member. 5.10 Retrospective Review Retrospective reviews are conducted upon request to determine the medical necessity of treatment that was rendered without pre-authorization. Sendero’s RN Care Coordinators have the authority to approve all treatment that meets the Milliman/InterQual Criteria and to refer cases they are not able to authorize or questionable cases to the Medical Director for review. 5.11 Case Management Sendero’s Whole Person Health Support (WPHS) program addresses a Member’s longitudinal course of care including continuity and coordination among practitioners and sites of care both within behavioral health and between behavioral health and physical health. WPHS includes helping Members to access behavioral health care within the most efficient time frame by the most appropriate practitioner or in the most appropriate treatment setting. This includes helping and encouraging Members to have seven (7) and thirty (30) day followup after an inpatient stay for behavioral health illness. It is necessary to promote efficient use of benefits to maximize Member and family access to necessary care. In addition, Sendero has implemented intensive case management for Members who have been identified as high risk due to diagnosis, multiple admissions, life threatening suicide attempts or who require additional services and have complicating factors that, without concentrated intervention coordinated by Sendero, would result in further deterioration in the severity of illness. To speak with a nurse about a Member or to make a referral for WPHS for a member, please call Sendero’s Health Service’s Department at 1-855-297-9191. 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 43 of 184 5.12 Utilization Decisions Consistency of Application of UM Criteria Sendero uses Milliman Care Guidelines and InterQual Criteria for all utilization management decisions. The criteria are applied by utilization and case management staff and by the Medical Director. All preauthorization, concurrent, and retrospective review decisions as well as appeal determinations will reference the appropriate medical necessity criteria and indicate why the criteria were met or not met. Denials The Medical Director reviews all potential denials related to behavioral health diagnoses. A physician makes all medical necessity denial determinations for inpatient mental health and chemical dependency partial hospitalization, and intensive structured outpatient. The Medical Director may contact the provider requesting services for additional information or to discuss alternatives to care. The provider requesting services may request to consult with the Medical Director. The Medical Director will make at least two (2) attempts to contact the Member’s provider regarding a denial. Members and providers receive written notification of all denials. Denial notifications include the reason for the denial and instructions for requesting an appeal. Appeals For more information regarding appeal process, contact Network Management at the phone number below, or refer to “ST5 Complaints & Appeals” or “CH4 Complaints & Appeals” in this manual. 5.13 Responsibilities of Behavioral Health Providers Behavioral health providers and/or physical health providers, who are treating a behavioral health condition, are responsible for appropriate referrals to the Texas Department of Protective and Regulatory Services (TDPRS) for suspected or confirmed cases of abuse. They are also responsible to assure that any necessary pre-authorization activities take place and for the following: Assure the release of information consent form is signed by the Member. Refer Members with known or suspected physical health problems or disorders to the primary care provider for examination and treatment. Only provide physical health if a behavioral health provider is already rendering treatment for behavioral health conditions. Ensure that the patients know of, and are able to avail themselves of, their rights to execute Behavioral Health Advance Directives. Assure All STAR and CHIP Members that receive inpatient psychiatric services are scheduled for outpatient follow up and/or continuing treatment prior to discharge. The outpatient treatment must occur within seven (7) days from the date of discharge. Have policies and procedures in place on how to follow-up on Member missed appointments. 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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