PROVIDER MANUAL - Sendero Health Plans

More documents

Recommendations

Info

Sendero Provider Manual Page 52 of 184 Services Requiring Pre-authorization For Pre-authorization, contact the Health Services Department at the number at the bottom of this page, or via the internet. Please notify the Health Services Department at least three to five (3-5) business days prior to rendering the service to allow time for Sendero to complete the pre-authorization review process. All elective surgeries are performed on the day of admission unless, based on medical necessity, the Health Services Department has approved the admission the day prior to surgery. 6.5 Vision Services Sendero Health Plans offers vision services through a contracted vendor. This vendor is OptiCare Managed Vision. The vision benefit includes a routine eye exam, and eyewear. Vision services that are for medical conditions of the eye require Primary Care Physician’s referral to an Ophthalmologist. Questions regarding the routine vision benefit and services should be directed to OptiCare at 1-877-615-7720 for CHIP and STAR. 6.6 Emergency Prescription Supply A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization is not available. This applies to non-preferred drugs on the Preferred Drug List and any drug that is affected by a clinical or prior authorization edit and would need prescriber prior approval. 6.7 Chiropractic Services Chiropractic services are available for Members. Visits do not require a referral from the member’s primary care physician nor pre-authorization unless they exceed 8 visits. The services are limited to treatment for spinal subluxation only. For pre-authorization, call or fax the Sendero Authorization and Referral Form or the Texas Authorization and Referral Form (see Appendix A) to Sendero’s Health Services Department to the numbers listed at the bottom of this page. Requests may also be made online via our website www.senderohealth.com. 6.8 Transplant Services Providers who are caring for Members under consideration for transplant services must notify Sendero. An RN Care Coordinator will become involved with this Member and follow them through the pre-transplant and final 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 53 of 184 transplantation process. Sendero requires pre-authorization for admission to any transplant facility. Any nationally recognized facility will be evaluated for approval based on the medical necessity of services for the Member. For prior approval and to notify of potential transplantation, contact the Sendero Health Services Department at the phone number at the bottom of this page. 6.9 Case Management Program Sendero provides case management services for catastrophic medical cases or for specific types of health care services through the Whole Person Health Support (WPHS) program which can be contacted at 1-855-297- 9191. Case management activities are performed by Sendero Health Services’ RN Care Coordinators. The RN Care Coordinator works closely with the Member's primary care provider to monitor the Member's health by tracking and reviewing the Member's utilization trends (inpatient admissions, office visits, pharmacy, etc.). The RN Care Coordinator determines whether coordination of services will result in more appropriate and cost effective care through treatment plan intervention and helps develop a proposed treatment plan. Members may be referred to the Whole Person Health Support program by calling into Health Services at 1-855-297-9191, completing a WPHS Referral form (Appendix A) and faxing it to 1-512-275-2862, or entering a referral online at www.SenderoHealth.com. Referrals are accepted by any person or provider with a concern, such as: A child's family/self-referral Customer Services Referral Behavioral Health Referral Member Satisfaction Surveys State developed Assessment tool Primary Care Provider/ Provider Referral Community/ External Agency Referral Analysis of claims utilization reports Administrator Contract for any State program Patients with high risk diagnoses or conditions may trigger WPHS intervention. Sendero’s WPHS program involves the Member, family or significant others, physicians, social services, community resources and facility team members, all of whom contribute to decisions regarding care. When appropriate, the Care Coordinator refers the Member and family to public health resources. A partial listing of these resources may include the following: Texas Health and Human Services Commission (HHSC) Supplemental Nutrition Assistance Program (SNAP) Women, Infants, and Children Program (WIC) Early Childhood Intervention Program (ECI) Texas Department of State Health Services (DSHS) Texas Department of Aging and Disability Services (DADS) Local School Districts as appropriate Texas Information and Referral Network (2-1-1, TIRN) Texas Department of Rehabilitative Services (DARS) 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 11 and 12: Sendero Provider Manual Page 11 of
Page 51: Sendero Provider Manual Page 51 of
Page 103 and 104:
Sendero Provider Manual Page 103 of
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?