PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 49 of 184
Referral Procedure
When a referral to a Sendero Specialist or ancillary facility is necessary, the following steps should be taken:
The primary care provider selects a Specialist from the Sendero network panel.
The primary care provider arranges for services with the Specialist in the usual manner including
coordination of pertinent clinical information and then issues a referral. A referral form is sent to the
specialist by using either the Sendero Referral logo form or the Texas Authorization and Referral Form in
Appendix A of this manual or online via the internet.
The Specialist will examine and treat the Member (as requested by the primary care provider) and document
recommendations and treatment. The Specialist should keep the primary care provider continually informed
of findings and treatment plans.
The Specialist will submit a claim form to Sendero. For further details regarding claim filing, please see
“7.0 Billing and Claims” in this manual.
If the Member requires additional services not directly associated with the diagnosis in the referral, the
Specialist must contact the primary care provider prior to rendering the additional care to coordinate these
services.
Primary Care Provider Referrals to Specialists
A Member’s referral is usually initiated during an office visit to the primary care provider. Referrals usually
include visits to the Specialist through the Member’s enrollment period.
Referrals should be issued prior to the visit to the Specialist (with the exception of emergency room and
behavioral health initial evaluation).
Specialist to Specialist Referrals
When a specialist wishes to refer to another specialist they need to refer the patient back to the primary care
provider to initiate the physician to physician referral. Specialists can, however refer patients for in network
ancillary services that fall under the scope of their practice. (For example, an Orthopedic Specialist can make a
referral for Physical Therapy or Occupational Therapy.) Specialists should ensure that the primary care
providers are kept informed of the results of any examinations and any additional treatment recommended.
Self-Referral Services
Members are allowed to self-refer, without a primary care provider referral, for the following services:
Emergency care
Routine vision care, other than surgery form a Network Therapeutic Optometrist or Ophthalmologist
OB/GYN care
Behavioral Health Services
Texas Health Steps examinations (STAR Members only)
Family Planning (STAR Members only)
Out-of-Network Referrals
Request for services by non-contracted providers, out of area / out of network services require Pre-authorization
by the Health Services Department. The pre-authorization will require that the requesting provider submit the
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)