PROVIDER MANUAL - Sendero Health Plans

Sendero Provider Manual Page 78 of 184
Covered benefit Authorization/Notification Required Comments
Hospital Services
Facility is responsible for notification
of ALL inpatient admissions.
Prior authorization of an emergent,
or scheduled admission is NOT
required.
Laboratory
No authorization for in-network provider
labs
Inpatient admissions for childbirth
does not require authorization
unless the length of stay exceeds
two (2) days for vaginal delivery of
four (4) days for C/Section
Medical Checkups No authorization required Checkups for Members under the
age of 21 are covered under the
Texas Health Steps Program
Optometry and Vision
Oral Evaluation and Fluoride
Varnish
Routine eye exams are provided
through subcontractor – OptiCare
Managed Vision. Contact OptiCare
for specific information
No authorization required
Contact phone number:
1-866-838-7614
For ages six (6) through thirty-five
(35) months as part of the Texas
Health Steps visit
Podiatry
No authorization required
Prenatal Care No authorization required Please submit Sendero’s Pregnancy
Notification Form
Primary Care Services
No authorization required
Radiology, Imaging, and X-rays
Authorization required for CAT
Scans, MRI/MRA not provided in an
inpatient or Emergency Room setting
PET Scans/SPECT
Radiological procedures that require
admission for observation
OB ultrasounds >3
No other authorization required if
performed at in-network facility and innetwork
provider
Specialty Physician Services
Therapies – Physical, Speech,
Occupational
Texas Health Steps
Transplantation of organs and
tissues
Referral from the PCP is required
Authorization is required only for
Chiropractic care > 8 visits
Organ or bone marrow transplants
Authorization required for PT, ST or
OT > 8 visits
No authorization required
May self-refer to any approved Texas
Health Steps provider regardless of
network affiliation
Prior Authorization is required
Prior authorization not required for
initial evaluation
STAR/Medicaid Program Limitations and Exclusions
Refer to the Texas Medicaid Provider Procedures Manual and the bi-monthly Texas Medicaid Bulletin for the
most current information regarding Program limitations and exclusions. The following is the list as of 2011, of
limitations and exclusions: (This list is not all inclusive.)
Autopsies.
Biofeedback therapy.
Care and treatment related to any condition for which benefits are provided or available under Workers’
Compensation laws.
Cellular therapy.
Chemolase injection (chymodiactin, chymopapain).
Custodial care.
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)