PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 76 of 184
The geographic area served by Sendero Health Plans is a mandatory enrollment area. All persons eligible for
Medicaid in the Temporary Aide to Needy Families (TANF) category or in the child categories, must enroll in a
health plan and select a primary care provider who participates in that health plan’s network.
ST 1.4 Span of Eligibility (Members’ Right to Change Health Plans)
You can change health plans by calling the Texas MEDICAID MANAGED CARE Program Helpline at 1-800-
964-2777. However, you cannot change from one health plan to another health plan while you are in the
hospital as a patient.
If you call to change health plans on or before the 15 th of the month, the change will take place on the first day
of the next month. If you call after the 15 th of the month, the change will take place the first day of the second
month after that. For example:
If you ask to change plans on or before April 15, the change will take place on May 1.
If you ask to change plans after April 15, the change will take place on June 1.
ST 1.5 Disenrollment from Health Plan
STAR/Medicaid
A request to remove a Member from the health plan must be forwarded to HHSC. Providers must provide
adequate documentation to justify disenrollment, and there must be sufficient compelling circumstances to
warrant disenrollment. The provider cannot make this request as retaliatory action against the Member. The
primary care provider or other provider must submit medical records to justify the request. All requests and
documentation will be forward to HHSC to make the determination. HHSC has the final decision authority.
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)