PROVIDER MANUAL - Sendero Health Plans

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)