PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 61 of 184
7.18 Billing for Hospital Observation Services
Facilities are eligible to receive reimbursement for Observation Admissions congruent with CMS rules (up to
72 hours). Sendero considers an observation claim to be an outpatient claim. In the itemized charges section of
the claim form, a line showing the UB Revenue Code should be shown with the number of hours of
observation. In cases where an observation stay is converted to inpatient, the facility should notify the Health
Services Department at the phone number below. Labor and Delivery Observation Stays require notification.
7.19 Coordination of Benefits (COB) Requirements
Sendero utilizes a third party vendor to verify COB status on all Sendero Health Plans Members. Verified
information obtained through this process will take precedent on all claim processing. For more information on
other coverage please contact Customer Services. For further information on COB claims, please contact your
Network Management Representative.
Sendero is the payer of last resort. Providers must bill all other carriers and receive payment or denial prior to
billing Sendero.
Other Payer Makes Payment: In cases where the other payer makes payment, the CMS-1500, CMS-1450, or
applicable ANSI-837 electronic format claim must reflect the other payer information and the amount of the
payment received.
Other Payer Denies Payment: In cases where the other payer denies payment, or applies their payment to the
Member’s deductible, a copy of the applicable denial letter or Explanation of Payment (EOP) must be attached
with the claim that is submitted to Sendero.
7.20 Billing Members
Balance billing is billing the Member for the difference between what a provider charges and what Sendero or
any other insurance company has already paid. Providers are not allowed to “balance bill” Sendero Members
except as noted below. All covered services are included within the payment made by Sendero and the residual
balance of covered charges must be written off as a contractual allowance. Providers are prohibited from billing
or collecting any amount from a Medicaid STAR Member for Health Care Services. Federal and state laws
provide severe penalties for any provider who attempts to bill or collect any payment from a Medicaid recipient
for a Covered Service. The following table illustrates circumstances concerning billing Members.
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)