PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 62 of 184 Member Billing Situations SERVICE PLAN PAYS NOTHING PLAN PAYS CONTRACTE D RATE PLAN PAYS USUAL & CUSTOMARY PROVIDER CAN BILL MEMBER if an Advance Beneficiary Notice and Private Pay Form was Executed Prior to Rendering the Services PROVIDER CANNOT BALANCE BILL MEMBER IN NETWORK Authorized Not Authorized OUT-OF-NETWORK Authorized Not Authorized EMERGENCY CARE In Network Out-Of- Network Non- Covered Services See “STAR – B – STAR/Medicaid Covered Services” or “CHIP – B – Covered Services” in this manual Co-pay Amounts for STAR/Medicaid Members: There are no co-payments for STAR/Medicaid Members. Co-pay Amounts for CHIP Members: Providers may collect co-pay amounts from CHIP Members as outlined below or on the Member’s CHIP identification card. Co-pay Amounts for CHIP Perinatal Members: There are no co-payments for CHIP Perinatal Members. 7.21 Collecting from or Billing CHIP Members for Co-pay Amounts Some CHIP Members have co-pay amounts for certain services. The Members’ Sendero identification card will indicate the co-pay amounts for these specific services. Only valid co-pay amounts can be collected from CHIP Members. For a list of when a co-pay applies, refer to Chapter 4.0 of this Provider Manual. 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 63 of 184 7.22 Billing Members for Non-covered Services Providers may not bill Members for non-covered services UNLESS the provider has obtained a signed Member Acknowledgement Statement or a Private Pay Form (see Appendix A) from the Member or guarantor prior to furnishing the non-covered service. These forms must be maintained in the provider’s records and made available to Sendero, HHSC, or agents of HHSC upon request. • Member Acknowledgement Statement Form The provider obtains and keeps a written Member Acknowledgement Statement, signed by the Member, when a Member agrees to have services provided that are not a covered benefit for STAR/Medicaid or CHIP. By signing this form, the Member agrees to have the services rendered, and agrees to personally pay for the services. (See Appendix A for a copy of this form.) • Private Pay Form Agreement The provider obtains and keeps a written Private Pay Form Agreement, signed by the Member, when the Member agrees to have services provided as a private paying patient. By signing this form, the Member agrees to pay for all services, and the provider will not submit a claim to Sendero. (See Appendix A for a copy of this form.) 7.23 Providers Required to Report Credit Balances Providers are required to report credit balances on accounts of Sendero Members within 60 days of the credit balance occurring on the account, if the credit balance was caused by: (a) Receiving payment from both Sendero and another payer, or (b) Receiving duplicate payment from Sendero. 7.24 Filing an Appeal for Non-payment of a Claim All claim appeals must be filed within 120 days of the date of the Explanation of Payment (EOP). To submit an appeal regarding claim payment, please submit a completed claim form, a copy of the EOP with the claim in question, and a written explanation of your appeal which should identify as “Administrative Claims Appeal” or “Corrected Claim” for appropriate processing to: Valence Health 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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