PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 51 of 184
procedure or course of treatment, appropriate level of service and the length of confinement prior to the delivery
of services. The clinical information provided aids in the medical review of the request.
Sendero provides prospective, concurrent, and retrospective utilization review services. All services that
require pre-authorization must be phoned or faxed to the Health Services Department utilizing either the
Sendero Authorization and Referral Form or the Texas Authorization and Referral Form included in Appendix
A of this manual. The request may be submitted via the internet as well.
Failure to obtain pre-authorization may result in non-payment of claims and encounters.
Members may request reconsideration of benefit determinations in accordance with the medical appeals
process. Physicians are responsible for making medical treatment decisions in consultation with their patients.
Any denial of pre-authorization based on lack of medical necessity or documentation of such, will be made by
the Medical Director.
All decisions made by the Health Services Department are subject to appeal using the provider appeal process
as described in “ST5 Complaints & Appeals” or “CH4 Complaints & Appeals” in this Manual.
Protocols and procedure for obtaining Pre-authorization
The physician (primary care provider or Specialist) initiates a pre-authorization using the same procedure as
requesting a referral, by calling or by faxing either the Sendero Authorization and Referral Form or the Texas
Authorization and Referral Form (see Appendix A) to Sendero’s Health Services Department and providing the
same demographic and clinical information as required for a referral as stated above. Pre-authorizations can also
be initiated over the internet and provider offices with internet access have been instructed in this procedure.
Provider offices interested in additional information on entering web based requests can call Network
Management at the phone number listed on the bottom of this page.
Definition of Admissions:
Elective Admission: Elective, or pre-planned, admissions generally include elective surgeries and admissions
for elective treatment that requires an acute care setting for management.
Observation Admission: Observation admissions are intended for use when it is necessary for a Member to be
monitored for a longer period of time post-operatively, or if the member has known risk factors or medical
conditions requiring frequent monitoring by the nursing staff. Observation is authorized for up to 72 hours
following Medicare guidelines. If the decision to keep the patient beyond 72 hours, the hospital or the attending
physician should contact Sendero within one (1) business day.
Direct Urgent Admissions: Urgent admissions are defined as those admissions that take place upon direct
referral from a physician’s office or when the Member is directed by a physician to go to the hospital. The
facility is required to notify Sendero within 24 hours or next business day of the admission.
Emergency Admissions: An emergency admission usually occurs directly from a hospital emergency facility
following evaluation and stabilization of a medical condition of recent onset and severity. These admissions
may occur after regular business hours. The facility must contact the Health Services Department within 24
hours or the next business day.
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)