PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 56 of 184
7.5 Timeliness of Billing
Claims and/or encounters must be submitted as follows:
Type of Claim
Professional Claims submitted on a CMS-
1500 or using the professional ANSI-837
electronic claim format
Ancillary Services Claims submitted on a
CMS-1500 or using the professional ANSI-837
electronic claim format
Ancillary Services Claims for services that are
billed on a monthly basis submitted on a CMS-
1500 or using the professional ANSI-837
electronic claim format (e.g. home health or
rehabilitation therapy)
Outpatient Hospital Services billed on the
CMS-1450 (UB04 institutional claim form) or
using the institutional ANSI-837 electronic
claim format
Inpatient Hospital Services claims billed on
the CMS-1450 (UB04 institutional claim form)
or using the institutional ANSI-837 electronic
claim format
Timely Billing Parameter
95 days from DATE OF SERVICE
95 days from DATE OF SERVICE
95 days from the LAST DAY OF THE
MONTH for which services are being
billed
95 days from the DATE OF SERVICE
95 days from the DATE OF DISCHARGE
Claims not submitted in accordance with the above noted deadlines may be denied.
Please do not submit a duplicate claim from original submission date prior to thirty (30) days for
electronic claims, and forty-five (45) days for paper claims.
7.6 Timeliness of Payment
Sendero will pay all clean claims submitted in the acceptable formats as previously detailed within thirty (30)
days from the date of receipt or the date that the claim is deemed “clean”. Should Sendero fail to pay the
provider within the thirty days, the provider will be reimbursed the interest on the unpaid claim at a rate of 1.5%
per month (18% annum) for every month the claim remains unpaid.
Sendero will pay all clean electronic pharmacy claims submitted in the acceptable format within eighteen (18)
days from the date of receipt or the date that the claim is deemed “clean”. Should Sendero fail to pay the
provider within the eighteen (18) days, the provider will be reimbursed the interest on the unpaid claim at a rate
of 1.5% per month (18% annum) for every month the claim remains unpaid.
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)