PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 75 of 184
ST1 – Eligibility of Members
ST 1.1 HHSC Determines Eligibility
The Texas Health and Human Services Commission (HHSC) are responsible for determining CHIP and
STAR/Medicaid eligibility. For information regarding eligibility, contact HHSC’s STAR hotline at 1-800-964-
2777.
For other help, call Sendero’s Customer Services at 1-855-526-7388.
ST 1.2 Role of Enrollment Broker
HHSC uses an Enrollment Broker to receive and process applications for STAR/Medicaid and CHIP. The
enrollment broker cannot authorize or determine eligibility. The role of the enrollment broker is to ensure that
all required documentation and forms are gathered. Once eligibility is determined by HHSC, the enrollment
broker mails out welcome letters and information on the available health plans in each area. The enrollment
broker receives each Member’s plan and primary care provider selection documentation and notifies health
plans of their new Members.
ST 1.3 General Eligibility for STAR/Medicaid
Beginning June 2011, the Texas Health and Human Services Commission (HHSC) introduced a new system
that uses digital technology to streamline the process which includes a new card that all STAR Members will
receive. This card is their new “Your Texas Benefits Medicaid ID card” which will take the place of the
monthly Medicaid Form 3087. Also in the new process is an online website where Medicaid providers can get
up-to-date information on a Member’s eligibility and history of services and treatments paid by Medicaid. The
enrollment period will remain for a six month period for Medicaid Members. The STAR ID card includes the
Member’s name and ID number, Managed care program enrolled in, Date card was issued, Health plan names
and phone numbers and other billing and pharmacy information.
If a STAR Member loses their “Your Texas Benefits Medicaid card” and needs proof of eligibility, HHSC staff
can generate a Temporary Medicaid Eligibility Verification Form (Form 1027-A). Members must apply for the
temporary form in person at an HHSC benefits office.
If a Member becomes temporarily (for six months or less) ineligible for Medicaid and regains eligibility status
during the initial six-month timeframe, the Member will be automatically re-enrolled in the health plan they
were in when eligibility was lost. The Member at this time may choose to switch plan.
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)