PROVIDER MANUAL - Sendero Health Plans

More documents

Recommendations

Info

Sendero Provider Manual Page 8 of 184 Billing/Claims Medicaid STAR and CHIP Mailing Address Electronic Claims Valence Health Clearinghouse of choice Attn: SENDERO CLAIMS P.O. Box 3869 EDI Payor ID: 36426 Corpus Christi, TX 78463 *Please review Acceptance and Rejection Report from your Clearinghouse of choice – All claims received in through Emdeon to 3 rd party payor 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 9 of 184 CHIP and STAR PRIOR AUTHORIZATION LIST SENDERO HEALTH PLANS EFFECTIVE 03/01/2012 Medical benefits and eligibility must be verified prior to requesting authorization. Admission notification and Prior Authorization requests can be submitted: ONLINE: www.SenderoHealth.com or FAX: 1-512-275-2862 or PHONE: 1-855-297-9191 The following services must be prior-authorized before rendering the service: Inpatient/Skilled Nursing Facility Services o Prior authorization of an emergent, elective or scheduled admission is NOT required o Facility is responsible for admission notification to Sendero o Prior day admissions for surgical procedures Ancillary/Specialty Services o Chiropractic care > 8 visits o Organ or bone marrow transplants o o Renal Dialysis Notification only of Hospice Services Treatment Related Services o o o o Investigational or Experimental drugs or procedures New Technologies Implantable pumps & devices Clinical trials covered by CMS Behavioral Health o Prior authorization of an emergent, elective or scheduled admission is NOT required. o Facility is responsible for admission notification to Sendero o Behavioral Health outpatient treatments >20 visits o Psychological and Neuropsychological Testing DME/Orthotics/Prosthetics o DME (rental or purchase) and medical supplies > $500 purchase price o o o Wound VACs Orthotics, Prosthetics or Dental devices purchase price >$500 per item Hearing Aids Out of Network or Area Services o All out of network or out of area inpatient, outpatient hospital admissions, surgeries, procedures, referrals, evaluations, specialty services and/or treatments Surgeries/Procedures (Inpatient or Outpatient ) o Circumcision >1 year of age o Cochlear Implants o Hyperbaric treatment for wound care o Bariatric Surgery (STAR) o Surgeries with potential cosmetic indications (i.e., panniculectomies, blepharoplasties, etc…) Radiology o CAT Scans, MRIs & MRAs not provided in an inpatient or Emergency Room setting o PET Scans/SPECT o Radiological procedures that require admission for observation o OB ultrasounds >3 o Transportation Non-emergent ground and air ambulance services Outpatient Services/Treatment o Bio-feedback o Injectable drugs > $500 AWP o Sleep studies / sleep labs o TMJ treatment o Synagis o Prevnar for children > 5 yrs of age o PT, ST or OT (excluding initial evaluation) Home Health o Skilled nursing visits > 3 visits o PT, ST or OT (excluding initial evaluation) o Infusion therapy o Private duty nursing 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)
Page 1 and 2: Sendero Provider Manual Page 1 of 1
Page 7: Sendero Provider Manual Page 7 of 1
Page 11 and 12: Sendero Provider Manual Page 11 of
Page 59 and 60:
Sendero Provider Manual Page 59 of
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
show all

PROVIDER MANUAL - Sendero Health Plans

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?