PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 98 of 184 with the Health and Human Services Commission (HHSC) at 1-800-252-8263. A complaint may be filed orally, or in writing. A complaint form will be sent to the complainants who file a verbal complaint. To file a verbal complaint, the Member should call 1-877-220-6376. An acknowledgement letter will be sent within five (5) days of receiving the complaint, with a complaint form, if applicable. All complaints are reviewed and a response sent within thirty (30) days of receipt of the complaint. Complaint Appeal If the provider, Member, or someone acting on behalf of the Member (“Appellant”), is not satisfied with the response of the complaint, they may file an appeal. Information regarding the appeal of the complaint decision is included with the decision response. The appeal must be in writing. Appeal decisions are made within thirty (30) days of receiving the appeal. Included in the appeal letter is the process used to make the determination. Member Appeal Process for Denial of Services STAR/Medicaid Members have the right to appeal when services are denied. Listed below are common questions and processes that will provide information regarding this appeal course of action. • How will I find out if services are denied? Members and providers are notified of denials by a letter. If the denial is a medical necessity denial, the Medical Director issuing the denial will attempt to contact the requesting provider prior to rendering his decision to obtain additional information or discuss the situation with him/her. A denial letter is sent out within three (3) days of the Medical Director making the decision. • What can I do if Sendero denies or limits my Member’s request for a covered service? The Member, provider, or someone acting on behalf of the Member may file an appeal when a denial occurs. (See the Appeal of an Adverse Determination below for how to file this appeal.) Members also have a right to request an appeal for denial of payment for services in whole or in part. • Can Someone from Sendero Help Me File an Appeal? Members needing help with filing the appeal should call the STAR Customer Services toll free number and request this help. A Member Advocate will be available to help the Member. This includes help with filing an Expedited Appeal. Appeal of Adverse Determination for STAR Member The provider, Member, or someone acting on behalf of the Member (“Appellant”) has thirty (30) days from the date on the denial letter to appeal the determination. This may be requested verbally or in writing. If the request is received verbally, we will ask that this appeal be put in writing. If the provider is requesting the appeal, the Member, or someone acting on behalf of the Member, must sign this appeal. If more than ten (10) days is needed to appeal this denial, this must be requested. Sendero may grant up to an additional fourteen (14) days to appeal this denial. Sendero will send an acknowledgement letter within five (5) days of receiving the appeal. Sendero will complete the appeal review within thirty (30) days from receipt of the written appeal. If Sendero needs additional time for the review to obtain additional information, we will notify the appellant with the 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 99 of 184 rationale for needing more time. Please note that Appeals for denials of service for not being a covered benefit is a complaint, not an appeal for adverse determination. Members may be required to pay the cost of services furnished while the appeal is pending, if services were delivered before approval was given. In order to ensure that there is continuity of current authorized services, the Member, provider, or someone acting on behalf of the Member, should file the appeal on or before the later of: (a.) ten (10) days following the mailing of the notice of Action, or (b.) the intended effective date of the proposed Action. Expedited Appeal for STAR Member An expedited appeal can be requested when a decision needs to be made quickly based on the health status of the Member, and taking time for the standard appeal process could jeopardize the life or health of the Member. Requests can be made verbally or in writing. A Member advocate can help the Member with this process. For more information, or to request an expedited appeal, contact Customer Service at 855-526- 7388. Once the expedited appeal is received, a decision will be made within one business day from receipt. Sendero will make every effort to honor the Member’s request for an expedited appeal. If the rationale for request does not meet the definition of an expedited appeal (decision warranted quickly due to the Member’s critical health outcome), Sendero may deny the request to expedite the review. If this happens, the provider may intervene on the Member’s behalf and discuss the situation with the Medical Director. The provider should contact the Medical Director by calling Health Services at the number shown on this page. State Fair Hearing Information • Can I ask for a State Fair Hearing? If you, as the Member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want representing you. A provider may be your representative. You or your representative must ask for the fair hearing within 90 days of the date on the health plan’s letter that tells of the decision you are challenging. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either call Health Services at the number on the bottom of this page or send a letter to the health plan at: Sendero Health Plans ATTN: Complaint/Appeal Department Suite 510 2028 E Ben White Blvd Austin TX 78741 If you ask for a fair hearing within 10 days from the time you get the hearing notice from the health plan, you have the right to keep getting the service(s) the health plan denied, at least until the final hearing decision is made. If you do not request a fair hearing within 10 days from the time you get the hearing notice, the service the health plan denied will be stopped. 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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