PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 90 of 184 sent to the Member informing the Member of its denial of the requested service due to the incomplete documentation/information, and providing the Member an opportunity to request a fair hearing. ST 3.2 Alberto N Second Partial Settlement Agreement The Alberto N Second Partial Settlement Agreement requires Sendero to send notification to Members regarding denied nursing services and denied private duty nursing services. This applies to STAR/Medicaid Members under the age of 21. Denied Nursing Services When the Agency or its Contractor determines that the requested nursing services are not nursing services and that the documentation may support authorization of personal care services, the notice denying the nursing services will describe the basis for this determination, in accordance with the paragraph titled Notification for Reduction, Denial, Termination of Services Not Medically Necessary (paragraph 18 of the Partial Settlement Agreement effective April 19, 2002). The notice will include template language briefly describing the Personal Care Services benefit and where and how to request prior authorization for Personal Care Services. The template language to be used is as follows: “The medical information received may support authorization of Personal Care Services. Personal Care Services are support services provided to Medicaid Beneficiaries under 21 year of age who require assistance with activities of daily living and health related functions because of a physical, cognitive, or behavioral limitation related to their disability to chronic health condition. For more information and to find out how to obtain Personal Care Services for a Medicaid Beneficiary under 21 years of age, you should contact Sendero Health Plans.” Denied Private Duty Nursing Services When Sendero determines that the services requested do not support a request for Private Duty Nursing services because the services could be provided on a per-visit basis through Home Health Skilled Nursing services, the notice denying the Private Duty Nursing services will describe the basis for this determination, in accordance with the paragraph titled Notification for Reduction, Denial, Termination of Services Not Medically Necessary (paragraph 18 of the Partial Settlement Agreement effective April 19, 2002). The notice will include template language briefly describing the Home Health Skilled Nursing services benefit and where and how to request prior authorization for Home Health Skilled Nursing services. The template language to be used is as follows: “The medical information received may support authorization of Home Health Skilled Nursing services. Home Health Skilled Nursing services are nursing services provided on a per-visit basis. Home Health Skilled Nursing services may be provided to meet acute care needs or on an ongoing basis to meet chronic needs. For more information and to find out how to obtain Home Health Skilled Nursing services, you should contact Sendero Health Plans.” 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 91 of 184 ST4 – Texas Health Steps Program ST 4.1 What is the Texas Health Steps Program? Texas Health Steps is a special health care program for young adults, and teens, birth through age 20. Texas Health Steps is identified in federal law as the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service. These checkups are important and Members should set up an appointment with their primary care provider within 45 days of becoming a Sendero Health Plans’ Member. Even if a child looks and feels well, a Texas Health Steps checkup can find problems before they get worse and harder to treat. For information regarding the Texas Health Steps program, see the Texas Medicaid Provider Procedures Manual current edition which is available online at http://www.tmhp.com/Pages/Medicaid/Medicaid_THSteps_Program_Info.aspx. A Texas Health Steps medical checkup includes: Comprehensive health and development history (mental and physical) Comprehensive unclothed physical exam Appropriate immunizations Laboratory tests appropriate to age and risk Health Education/Anticipatory Guidance ST 4.2 How Can I Become a Texas Health Steps Provider? To become a Texas Health Steps provider, you will need to enroll through the Texas Medicaid and Healthcare Partnership (TMHP). Enrollment as a Texas Health Steps provider is separate from general Medicaid provider enrollment. Go to the website link to Provider Enrollment Support for Territory 7 at: http://www.tmhp.com/Pages/ProviderEnrollment/PE_Reg_7_Support.aspx . 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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