PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 82 of 184 Value Added Service Temporary Cell Phone Gifts for New Mothers Sports/School Physicals Extra Help with Getting a Ride Extra Dental Benefits Pregnant Women STAR Program SERVICE: Sendero will provide pre-programmed cell phones to pregnant Members who are determined to be high-risk. This service will permit these Members to be in touch on both inbound and outbound call with Sendero’s Health Services RN Care Coordinator and the PCP/OB in order to ask questions and receive advice, be reminded of appointments, arrange for transportation and to contact 911 in case of emergency. LIMITATION: As it applies only to female Members who are determined high-risk, limited to use during pregnancy and immediate postpartum period. SERVICE: Sendero will provide up to $50 worth of health items for pregnant Members who complete at least eight (8) prenatal visits to their OB during pregnancy. At least 1 gift will be for Member. LIMITATION: As it applies only to pregnant Members and the completion of the minimum required number of eight (8) prenatal appointments while a Member of Sendero. SERVICE: Sendero will reimburse its contracted PCP for an annual sports/school physical for children up to age 19 at the PCP’s contracted rate. LIMITATION: Only limitation is under age 19 SERVICE: Sendero will arrange transportation to physician appointments LIMITATIONS: plan reserves the right to determine medical necessity SERVICE: Sendero will pay for up to $250 in dental services each year for pregnant member LIMITATIONS: value limited to $250 and for pregnant members only ST 2.3 Family Planning Services Family Planning services, including sterilization, are covered STAR Member benefits. These services can be provided by any qualified HHSC approved family planning provider (regardless of whether or not the provider is in network for Sendero) without the prior approval from the PCP or Sendero. Family planning providers must deliver family planning services in accordance with the HHSC Family Planning Service Delivery Standards. Family planning services are preventive health, medical, counseling and educational services that assist Members in managing their fertility and achieving optimal reproductive and general health. Family planning services must be provided by a physician or under physician supervision. In accordance with the provider agreement, family planning providers must assure clients, including minors, that all family planning services are confidential and that no information will be disclosed to a spouse, parent, or other person without the client’s permission. Health care providers are protected by law to deliver family planning services to minor clients without parental consent or notification. 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 83 of 184 Only family planning patients, not their parents, their spouses or other individuals, may consent to the provision of the family planning services. However, counseling should be offered to adolescents, which encourages them to discuss their family planning needs with a parent, adult family Member, or other trusted adult. Sterilization services are a benefit for members who are at least 21 years of age when the consent form is signed. In the event that a Sendero Member aged 21 years or older chooses sterilization, providers must use the current state-approved sterilization consent form and complete at least thirty (30) days prior to the procedure, with some exceptions related to emergency surgery and premature delivery. These forms and instructions are available in both English and Spanish at www.tmhp.com by clicking on the Family Planning link under the Provider section. Providers may fax the completed form to Sendero Health Services Department at the fax number at the bottom of this page, or simply include the form with the completed claim form. ST 2.4 Non-Urgent Medical Transportation Services The Health and Human Services Commission provides medical transportation services for STAR patients that have no other means of transportation for medical and dental appointments. The transportation program will utilize the most cost-effective method of transportation that does not endanger a patient’s health, to include an ambulance or wheelchair van. To request medical transportation services, a Member should contact the transportation program at: 1-877-633- 8747. To arrange for transportation, call at least 48 hours in advance of the office visit, Monday through Friday, 8 a.m. to 5 p.m. ST 2.5 Coordination with Non-Medicaid Managed Care Covered Services: Non-Medicaid Managed Care Services include the following: Dental Services Beginning March 1, 2012 STAR and CHIP dental services are offered through a managed care model program for eligible recipients. Dental services are discussed in “ST4 – Texas Health Steps Program” or “CH2 – Covered Services” in this Provider Manual. For more information see the value added services listed for STAR and CHIP. Texas Agency Administered Programs and Case Management Services Texas Department of Family and Protective Services (DFPS): Sendero’s network of providers coordinates with DFPS (and associated foster parents) to ensure that the at risk population, both children in custody and not in custody of DFPS, receive the services they need. Children who are served by DFPS may transition into and out 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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