PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 68 of 184 Confidential information relating to a Member, including HIV/AIDS information will not be disclosed or published without the prior written consent of the patient, parent, family, or legal guardian. Any information that is no longer required confidential information is completely destroyed (i.e. shredded, etc.). 8.8 Focused Studies and Utilization Management reporting requirements In conjunction with the QI Work Plan, Sendero Health Plans conducts focused studies to look at the quality of care. Examples of focused studies would be those regarding diabetes care and treatment, and asthma care and treatment. The QI Work Plan is developed annually, and focused studies may be added at this review. Other Utilization Management reports that are produced monthly and reviewed at the Provider Advisory Subcommittee and the Behavioral Health Subcommittee meetings, as well as the QI Committee are as follows: Review of admissions and admission/1,000 Members (Medical and Behavioral Health) Review of bed days and bed days/1,000 Members (Medical and Behavioral Health) Average length of stay for inpatient admissions (Medical and Behavioral Health) ER utilization and health services utilization/1,000 Members Denials and appeals Other reports as needed to evaluate utilization of services by Membership For information on any of the above reports, or to see one of these reports, contact the Health Services Director for Sendero at 512-978-8176. 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 69 of 184 9.0 – Credentialing and Re-credentialing 9.1 Credentialing and Re-credentialing Oversight The Provider Advisory Subcommittee (PAS) is led by Sendero’s Medical Director. One of its functions is to review and approve credentialing files of providers who apply to the Sendero Health Plans network. The Subcommittee meets as often as necessary to complete provider credentialing and re-credentialing activities. There are contemporaneous dated and signed minutes that reflect all Provider Advisory Subcommittee activity. Reports are then made to the Quality Improvement Committee. The main scope of the committee is to ensure that competent qualified practitioners and providers are included in Sendero Health Plans’ network and to protect the Members from professional incompetence. The Quality Improvement Committee and the Sendero Health Plans’ Board of Directors review all activities of the Provider Advisory Subcommittee related to the credentialing and the re-credentialing of providers for the Sendero network. If you are interested in the PAS, please contact the Health Services Director at 512.978.8176 for more information 9.2 Provider Site Reviews Site visits may be conducted at the offices of primary care providers, OB/GYN physicians, and high volume individual behavioral health providers, by your local Network Management Representative prior to initial credentialing at Sendero Health Plans. In addition, site visits will be conducted at any time for cause, including a complaint made by a Member or another external complaint made to Sendero Health Plans. High volume behavioral health providers and all psychiatrists, any behavioral health group or clinic of ten (10) or more practitioners, and all Community Mental Health centers may also have a site visit conducted prior to initial credentialing with Sendero Health Plans. The site visit review will consist of at least the following components: Physical Structure and Surroundings Provider Accessibility Provider Availability Confidentiality processes Treatment Areas Patient Education / Patient Rights Medical Record Review For Rural Health Clinics, if a Nurse Practitioner or Physician Assistant is the main provider, additional criteria are reviewed that includes: 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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