PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 58 of 184 7.9 E&M Consult Billing Requirements Sendero follows standard coding and billing requirements for consults (CPT codes 99241-99275). 7.10 Emergency Services Claims If emergency care is needed, it should be provided immediately in accordance with the procedures described in “4.0 - Emergency Services” in this manual. Services provided in an emergency situation will be reimbursed in accordance with the Hospital’s or provider’s agreement with Sendero. Non-participating providers and hospitals that provide Emergency care to Medicaid Members will be paid according to the Texas Medicaid allowable fee schedule. Providers within the service area who are non-participating will be paid according to the out of network Medicaid allowable fee schedule. 7.11 Use of Modifier 25 Sendero will accept modifier 25 codes when submitted in accordance with the following requirements: Modifier 25 is used on a valid CPT or HCPCS procedure code to indicate that the identified service was provided as a distinctly separate service from other similar services furnished on the same date of service. EXAMPLE: Providing an age-appropriate health screening on the same day as a sick visit. Sick Visit Preventive Screen Select the appropriate E&M Office Visit Code Select the age-appropriate preventive E&M Code and affix the 25 modifier. Providers may use the modifier 25 when billing an E&M code with another significant procedure on the same day. The modifier 25 should be affixed to the E&M code only. The medical record should clearly support the significance and distinctiveness of the associated procedure. The modifier 25 may also be used to bill a preventive health screen, or Texas Health Steps exam, performed on the same day as a sick visit. The modifier 25 should be affixed to the preventive screen code. The Sendero Fraud, Waste and Abuse (FWA) special investigative unit monitors modifier 25 billings. Occasional chart audits are performed to comply with our FWA program requirements. 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 59 of 184 7.12 Billing for Assistant Surgeon Services Sendero provides coverage for Assistant Surgeon services authorized in accordance with Sendero policies for certain CPT codes. 7.13 Billing for Capitated Services Capitated providers are required to submit encounter claims for all capitated services. Sendero accepts encounter data on the CMS-1500 form or the professional ANSI-837 electronic format. The forms should be completed in the same manner as a claim. For a complete list of capitated services along with applicable carve outs and allowables please refer to your provider contract. 7.14 Billing for Immunization and Vaccine Services Childhood Immunizations: Primary care providers who furnish immunization services for children are required to enroll with the Texas Vaccine for Children (TVFC) program. The program provides vaccines for childhood immunization. Sendero does not reimburse for vaccines, but will reimburse primary care providers for the administration of the vaccine(s). Adult Immunizations: Sendero covers adult immunization services. Providers may bill for both the vaccine (using the appropriate HCPCS code) and for vaccine administration. 7.15 Billing for Texas Health Steps (Medicaid STAR only) or Well Child Visit Services Texas Health Steps providers are required to submit claims for all Texas Health Steps services in the acceptable formats previously detailed. Additionally, Texas Health Steps providers must send all Texas Health Steps newborn screen to the Texas Department of State Health Services (DSHS), Bureau of Laboratories or a DSHS certified lab. Texas Health Steps providers must include detailed identifying information for all screened newborn Members and the Member’s mother to allow HHSC to link the screens performed at the hospital with screens performed at the two-week follow-up. Billing for services outside of the Periodicity schedule listed in “ST4 – Texas Health Steps Program” or “CH3 – Well Child Visits” in this manual will only be paid for exceptions listed in that section. The website link to access the THSteps Periodicity Schedule is www.dshs.state.tx.us/thsteps/Periodicity-Schedule-THSteps_bw.doc. 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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