PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 92 of 184 ST 4.3 Finding a Texas Health Steps Provider If you are not a Texas Health Steps provider, you may locate an in-network Texas Health Steps provider by reviewing your Sendero Provider Directory. ST 4.4 Texas Health Steps Periodicity Schedule Providers are required to follow the STAR/Medicaid Texas Health Steps periodicity schedule, to complete Texas Health Steps exams. This information may be found in the Texas Medicaid Provider Procedures Manual at http://www.dshs.state.tx.us/thsteps/providers.shtm ST 4.5 Eligibility for Texas Health Steps Exam STAR/Medicaid Members are periodically eligible for a Texas Health Steps exam. The Member’s new Medicaid ID card will indicate that the Member is currently eligible. Verification of benefits and eligibility will assist to identify if a Member has eligibility for the particular service, such as eye exam, eye glasses, hearing aid, and medical services. ST 4.6 Timely Texas Health Steps Exam Sendero would like to ensure Medicaid enrollees get a timely Texas Health Steps exam within the year of their birthday or enrollment date. If the Members birth date/eligible date is past and you do not have record of a Texas Health Steps exam and the parent does not indicate they had one elsewhere, you do not need to wait for the indication on the enrollment state card, or for the Member to have a reminder letter from the state. Perform the exam, and Sendero will pay for those services. Sendero will be implementing provider incentive programs to acknowledge your cooperation with the Texas Health Steps program as the Patient Centered Medical Home approach to primary care continues to expand. ST 4.7 Exams outside the Texas Health Steps Periodicity Schedule Exams provided when a Texas Health Steps statement does not indicate a medical checkup is due, must be billed as an exception to the periodicity schedule. The claim must be submitted with the appropriate modifier. Payment will be made for these exceptions if the services are provided under the following categories: 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 93 of 184 Medically necessary (such as developmental delay or suspected abuse) Environmental high risk (such as a sibling of a child with elevated blood lead) Required to meet state or federal exam requirements for Head Start, day care, foster care, or preadoption Required for dental services provided under general anesthesia ST 4.8 Texas Health Steps Exams for Newborns Inpatient newborn examinations are counted as Texas Health Steps medical checkups and must include all the necessary components. The required components of the initial newborn checkup are: History and physical examination Length, height, weight, and head circumference Sensory screening (vision and hearing appropriate to age) Hepatitis B immunization Neonatal genetic/metabolic screen Health education with the parents or a responsible adult who is familiar with the child’s medical history. ST 4.9 Immunization Requirements for Children Immunization requirements for children are defined on the Texas DSHS website at http://www.dshs.state.tx.us/immunize/Schedule/schedule_child.shtm Providers are required to participate with the Texas Vaccines for Children Program. (See next page.) ST 4.10 Children of Migrant Farm workers Children of Migrant Farm workers due for a Texas Health Steps medical checkup can receive their periodic checkup on an accelerated basis prior to leaving the area. A checkup performed under this circumstance is considered an exception to periodicity. Performing a make-up exam for a late Texas Health Steps medical checkup previously missed under the periodicity schedule is not considered an exception to periodicity nor is it considered an accelerated service. It is considered a late checkup. 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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