PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 66 of 184 8.3 Sendero’s HEDIS ® Measurements Sendero Health Plans is required by the Health and Human Services Commission (HHSC) to conduct certain defined HEDIS ® measurements. Health Employer Data Information Sets (HEDIS ® ) are specified criteria defined by the National Committee for Quality Assessment (NCQA), the national accrediting agency for Health Maintenance Organizations (HMOs). The HHSC defined criteria includes, but are not limited to, the following: evaluation of well child examinations use of appropriate medications for Members with asthma mental health follow-up appointments following hospitalization (at 7 days and 30 days) prenatal and postpartum care Sendero provides encounter data to the HHSC-contracted External Quality Review Organization (EQRO). The EQRO evaluates all STAR and CHIP health plan claims and produces health plan report cards and HEDIS ® data. For more information regarding HEDIS ® criteria, and monitoring, contact Network Management at the number below. 8.4 Sendero’s Quality Improvement Committee Sendero Health Plans has a Quality Improvement (QI) Committee which is responsible for oversight and ensuring that quality processes and quality of care is provided to all Members. This committee is comprised of Pediatricians, Specialists, the Sendero Health Plans’ CEO, the QI Manager, the Subcommittee Chairmen and other ad hoc Members as needed. All Sendero Subcommittees report to the QI Committee. Subcommittee chairmen provide updates at each QI Committee meeting. The QI Committee reviews and approves the annual QI Work Plan. Each committee meeting consists of review of areas associated with the work plan. In addition, all policies and procedures for Sendero are reviewed and approved by this committee. The QI Committee reports to the Sendero Health Plans’ Board of Directors. 8.5 How to Get Involved in Sendero’s Quality Program All providers are encouraged to participate in Sendero’s Quality Program. This includes participation in the QI Committee. For more information on how to participate in the Quality Program and/or the QI Committee, contact the QI Manager at 512-978-8085. 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 67 of 184 8.6 Provider Report Cards Sendero Health Plans prepares individual provider report cards that evaluate each provider’s performance as it relates to the care of the Members. The information is compiled from claims and utilization data and is compared to like providers so that a peer to peer assessment can be completed. For more information regarding the report card, the provider may contact Network Management at the number at the bottom of this page. 8.7 Confidentiality Each physician contracted with Sendero Health Plans (Sendero) must implement and maintain a policy which acts to ensure the confidentiality of patient information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Only healthcare providers treating a Member and essential Sendero employees involved in the coordination of a Member’s care are permitted access to medical records and Member-specific information. Essential personnel are defined as those with “a need to know”. All Member-specific information shall be maintained in a secure area both in the provider’s office and at the Sendero corporate and operational offices. Verbal and written exchange of Member-specific information is permitted when used for purposes of treatment, payment or operational procedures. Some examples of these purposes may be: During professional conferences, consultations and reports that are required as part of the Sendero Utilization Management or Quality Improvement programs. Between essential Sendero staff and the healthcare providers involved in the Member’s care. Healthcare providers include primary care providers, specialists, behavioral health providers and other persons involved in the direct care for a Member at in- and out-patient facilities. Only pertinent and essential health information will be communicated. The general rule of “the least amount of information required to accomplish the task” shall be followed in all cases. All Sendero records are the property of Sendero Health Plans. They may be removed from the Sendero jurisdiction and safe-keeping only in accordance with recognized statues of law, including but not limited to, court order or subpoena. Copies of hospital medical records of Sendero Members are released according to the policies and procedures of the Medical Records Department of the particular institution and their contract with Sendero. Copies of the physician office medical records may be released in compliance with state and federal regulations, and the terms of the individual physician’s or group’s contract with Sendero. Unauthorized release of confidential information by an employee or agent of Sendero will result in disciplinary action, in compliance with Sendero Health Plans’ Confidentiality Policy. 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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