PROVIDER MANUAL - Sendero Health Plans

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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)
Sendero Provider Manual Page 77 of 184 ST2 – STAR/Medicaid Covered Services ST 2.1 STAR/Medicaid Managed Care Covered Services Sendero Health Plans is required to provide specific medically necessary services to its STAR Members. The following table provides an overview of benefits. Please refer to the current Texas Medicaid Provider Procedure Manual available at www.tmhp.com and the bi-monthly Texas Medicaid Bulletin for a more inclusive listing of limitations and exclusions. ALL out-of-network services (other than emergency services) require prior authorization by the Health Services Department at Sendero Health Plans. Covered benefit Authorization/Notification Required Comments Ambulance Services No authorization required for emergent transport Authorization required for nonemergent transport Audiology Services Cochlear implants and augmentative devices require authorization Hearing aids for Members under age 21 are provided through TMHP Behavioral Health Services Authorization is required for: Facility is responsible for in patient admission notification Outpatient treatment >20 visits Psychological and Neuropsychological testing Prior auth of an emergent, elective or scheduled admission is NOT required and not Sendero Please see the Behavioral Health section of this manual for further guidelines. Chiropractic Services Chiropractic visit > 8 visits Limited to spinal subluxation, only. Dialysis Notification is required Durable Medical Equipment (DME) and Supplies Use of in-network supplier required Rental or purchase of DME and medical supplies >$500 (purchase price) Wound VACs Orthotics or Prosthetics purchase price >$500 per item Emergency Services No authorization required Family Planning Services No authorization required Members may access any family planning provider without network restriction. Annual family planning visit must include correct family planning modifier Home Health Care Services Skilled nursing visits > 3 visits PT / ST / OT > 8 Infusion therapy Private duty nurse Use of in-network provider / supplier required 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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