PROVIDER MANUAL - Sendero Health Plans

More documents

Recommendations

Info

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)
Page 1 and 2: Sendero Provider Manual Page 1 of 1
Page 3: Sendero Provider Manual Page 3 of 1
Page 11 and 12: Sendero Provider Manual Page 11 of
Page 55 and 56:
Sendero Provider Manual Page 55 of
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
show all

PROVIDER MANUAL - Sendero Health Plans

Create successful ePaper yourself

Delete template?

Save as template?