PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 94 of 184 ST 4.11 Texas Vaccines for Children (TVFC) Program The Texas Vaccines for Children Program provides free vaccines to STAR/Medicaid children who are younger than 19 years of age. TVFC automatically covers all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Centers for Disease Control and Prevention (CDC). To obtain free vaccine, the provider must enroll in the TVFC program through Department of State Health Services (DSHS). Vaccine is ordered through regional state offices. A TVFC provider may not charge for the vaccine itself, but is permitted to charge a reasonable administration fee. For more information, contact DSHS at 800- 252-9152 or 512-776-7284, or Network Management at the phone number listed below. See application form in Appendix A of this manual. ST 4.12 Texas Health Steps Lab and Testing Supplies Specific laboratory tests required as part of the Texas Health Steps exam must be submitted to the Department of State Health Services (DSHS) laboratory. Because these laboratory tests must be processed at the DSHS Laboratory, they cannot be billed as separate claims on the same date of service as a medical checkup. The tests that must be sent to the DSHS lab are Hemoglobin; Chlamydia, gonorrhea, and lead. The initial blood lead test may be done by point-of-care testing in the providers office, and billed for reimbursement. The following tests may be performed at a lab of the provider's choice: hyperlipidemia, type 2 diabetes, syphilis, or HIV. All newly enrolled Texas Health Steps providers receive a startup package of forms and supplies. Included in this startup package are blood specimen collection supplies. Additional supplies may be requested from DSHS Laboratory Services via fax at 1-512-776-7672 or via their website at: http://www.dshs.state.tx.us/lab/mrs_forms.shtm ST 4.13 Texas Health Steps Dental Screenings Pediatric (birth through age 20) dental services for STAR Members are covered under the Texas Health Steps program. Routine dental exams and services are available beginning at age six (6) months and once every six (6) months thereafter. These dental services are covered by the Texas Health Steps Dental Program through HHSC. Members can self-refer to participating dentists in the Texas Health Steps Dental Program. Neither a referral from the primary care provider nor authorization from Sendero is necessary for routine dental services. ST 4.14 Dental-oral Evaluation and Fluoride Varnish (OEFV) Dental-oral evaluation and fluoride varnish is covered by Sendero when provided in the PCP office for children from 6 to 35 months of age. Oral evaluation and fluoride varnish (OEFV) in the medical home has been 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 95 of 184 established to support the dental home concept. The oral evaluation and fluoride varnish application must be performed during a Texas Health Steps medical exam. A dental evaluation includes the following: Intermediate oral evaluation (must be done by a physician, nurse practitioner or physician assistant who has been certified by DSHS to perform OEFV) Fluoride varnish application This application may be delegated to nurses or medical assistants Referral to a dental home beginning at six (6) months of age. In conjunction with a Texas Health Steps medical checkup, utilize CPT code 99429 with U5 modifier when billing fluoride varnish. The oral evaluation/fluoride varnish must be billed with one of the following medical checkup codes – 99381, 99382, 99391, or 99392. Federally Qualified Health Centers (FQHC) should refer to the Texas Medicaid Provider Procedures Manual for further instructions on billing. ST 4.15 Texas Health Steps Vision Each Texas Health Steps checkup includes a vision screen based on the periodicity schedule. The Texas Health Steps Program provides one (1) eye examination per state fiscal year (September through August) and eyeglasses every two (2) years. Any diagnosed conditions or abnormalities of the eye that require additional services beyond the scope of an exam for refractive errors must be referred back to the Member’s primary care provider. Vision providers who render additional services, beyond refractive exams, must have a prior authorization. Routine eye exams are provided through Sendero Health Plans’ subcontractor, OptiCare Managed Vision. For information, please call OptiCare at 1-866-838-7614. ST 4.16 Referral for Services Identified During a Texas Health Steps Exam Referrals for services identified during a Texas Health Steps exam would occur as any other referral process. Contact the Health Services Department for more information regarding the referral process at the number listed at the bottom of this page. ST 4.17 Outreach to Members for Texas Health Steps Exams Sendero has an Outreach Call Center to help in making the Texas Health Steps appointments for STAR Members. The call center helps in the following: 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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