PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 54 of 184 Other child-serving civic & religious organizations and consumer & advocacy groups. March of Dimes American Heart Association American Lung Association The Care Coordinator arranges social services, community services and other services as needed, including DME. For more information regarding Sendero’s WPHS case management program or for additional information on the community agencies, contact Sendero’s Health Services Department at 1-855-297-9191. 6.10 Disease Management Programs Disease Management Programs are largely retrospective oversight of high risk medical conditions. Disease management is designed to prevent exacerbation of symptoms that might result in hospitalization. Disease management is also designed to help Members with specific illnesses deal more effectively with their disease or condition to as to improve their quality of life. Sendero’s Disease Management programs are a component of the Whole Person Health Support (WPHS) program. Currently, Sendero offers WPHS Programs for Attention Deficit Hyperactivity Disorders (and related conditions), Asthma, Diabetes, and high risk pregnancy. These services are designed to increase patient knowledge regarding their health, their disease process, nutrition, medication and importance of compliance with the introduction of community resources available to them. If you encounter a Member that you feel would benefit from one of these programs, please contact the Health Services Department by phone at 1-855-297- 9191, by completing a referral form (Appendix A) and faxing it to 1-512-275-2862 or by submitting a Referral form on line at www. SenderoHealth.com. An RN Care Coordinator will be available to help in facilitating the physician based treatment plan in a collaborative effort with the Member’s various healthcare providers to help in improving or maintaining the wellbeing of the Member. 6.11 Practice Guidelines Sendero Health Plans utilizes the American Academy of Pediatrics Practice Guidelines, as guidelines for care for the pediatric Members. In addition, Sendero uses the asthma practice guidelines from the National Heart Lung and Blood Institute. The immunization guidelines are followed as recommended by the American Academy of Pediatrics as are the ADHD Practice Guidelines. Sendero’s guidelines for management of Diabetes vary depending on the age of the individual and the pregnancy status. Questions regarding practice guidelines may be directed to the Health Services Department. See Clinical and Preventative Care Guidelines in Appendix C 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 55 of 184 7.0 – Billing and Claims 7.1 What is a Claim? A claim is a request for payment. Sendero uses the standard CMS-1500 (professional) and CMS-1450 (UB04 institutional) paper claim forms OR the ANSI-837 format for electronic claims submission for medical and behavioral health claims. 7.2 What is a Clean Claim? A clean claim is defined as a claim submitted by a physician or provider for medical care or health care services rendered to a Member, with the data necessary for Sendero to adjudicate and accurately report the claims. A clean claim must meet all requirements for accurate and complete data as defined in the 837 transaction guide. Once a clean claim is received, Sendero is required, within the thirty (30) day claim payment period to: Pay the claim in accordance with the provider contract, or Deny the entire claim, or part of the claim, and notify you why the claim or part of the claim was not paid. 7.3 Electronic Claims Submission: ANSI-837 Sendero accepts claims via 837 electronic claims submission utilizing Emdeon as our clearinghouse acceptance point. EDI Payor ID = 36426. Please verify that your current clearinghouse can be accepted by Emdeon or contact your Provider Relations Representative for assistance. 7.4 Submitting Paper Claims to Sendero Paper claim forms are mailed to: Sendero Health Plans ATTN: CLAIMS P.O. Box 3869 Corpus Christi, TX 78463 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)
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PROVIDER MANUAL - Sendero Health Plans

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