PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
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<strong>Sendero</strong> Provider Manual Page 53 of 184<br />
transplantation process. <strong>Sendero</strong> requires pre-authorization for admission to any transplant facility. Any<br />
nationally recognized facility will be evaluated for approval based on the medical necessity of services for the<br />
Member. For prior approval and to notify of potential transplantation, contact the <strong>Sendero</strong> <strong>Health</strong> Services<br />
Department at the phone number at the bottom of this page.<br />
6.9 Case Management Program<br />
<strong>Sendero</strong> provides case management services for catastrophic medical cases or for specific types of health care<br />
services through the Whole Person <strong>Health</strong> Support (WPHS) program which can be contacted at 1-855-297-<br />
9191. Case management activities are performed by <strong>Sendero</strong> <strong>Health</strong> Services’ RN Care Coordinators. The RN<br />
Care Coordinator works closely with the Member's primary care provider to monitor the Member's health by<br />
tracking and reviewing the Member's utilization trends (inpatient admissions, office visits, pharmacy, etc.). The<br />
RN Care Coordinator determines whether coordination of services will result in more appropriate and cost<br />
effective care through treatment plan intervention and helps develop a proposed treatment plan. Members may<br />
be referred to the Whole Person <strong>Health</strong> Support program by calling into <strong>Health</strong> Services at 1-855-297-9191,<br />
completing a WPHS Referral form (Appendix A) and faxing it to 1-512-275-2862, or entering a referral online<br />
at www.<strong>Sendero</strong><strong>Health</strong>.com. Referrals are accepted by any person or provider with a concern, such as:<br />
A child's family/self-referral<br />
Customer Services Referral<br />
Behavioral <strong>Health</strong> Referral<br />
Member Satisfaction Surveys<br />
State developed Assessment tool<br />
Primary Care Provider/ Provider Referral<br />
Community/ External Agency Referral<br />
Analysis of claims utilization reports<br />
Administrator Contract for any State program<br />
Patients with high risk diagnoses or conditions may trigger WPHS intervention. <strong>Sendero</strong>’s WPHS program<br />
involves the Member, family or significant others, physicians, social services, community resources and facility<br />
team members, all of whom contribute to decisions regarding care.<br />
When appropriate, the Care Coordinator refers the Member and family to public health resources. A partial<br />
listing of these resources may include the following:<br />
Texas <strong>Health</strong> and Human Services Commission (HHSC)<br />
Supplemental Nutrition Assistance Program (SNAP)<br />
Women, Infants, and Children Program (WIC)<br />
Early Childhood Intervention Program (ECI)<br />
Texas Department of State <strong>Health</strong> Services (DSHS)<br />
Texas Department of Aging and Disability Services (DADS)<br />
Local School Districts as appropriate<br />
Texas Information and Referral Network (2-1-1, TIRN)<br />
Texas Department of Rehabilitative Services (DARS)<br />
<strong>Sendero</strong> Customer Services 1-855-526-7388 Network Management 1-855-895-0475<br />
<strong>Health</strong> Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)