PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
PROVIDER MANUAL - Sendero Health Plans
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<strong>Sendero</strong> Provider Manual Page 99 of 184<br />
rationale for needing more time. Please note that Appeals for denials of service for not being a covered<br />
benefit is a complaint, not an appeal for adverse determination.<br />
Members may be required to pay the cost of services furnished while the appeal is pending, if services were<br />
delivered before approval was given.<br />
In order to ensure that there is continuity of current authorized services, the Member, provider, or someone<br />
acting on behalf of the Member, should file the appeal on or before the later of: (a.) ten (10) days following<br />
the mailing of the notice of Action, or (b.) the intended effective date of the proposed Action.<br />
Expedited Appeal for STAR Member<br />
An expedited appeal can be requested when a decision needs to be made quickly based on the health status<br />
of the Member, and taking time for the standard appeal process could jeopardize the life or health of the<br />
Member. Requests can be made verbally or in writing. A Member advocate can help the Member with this<br />
process. For more information, or to request an expedited appeal, contact Customer Service at 855-526-<br />
7388. Once the expedited appeal is received, a decision will be made within one business day from receipt.<br />
<strong>Sendero</strong> will make every effort to honor the Member’s request for an expedited appeal. If the rationale for<br />
request does not meet the definition of an expedited appeal (decision warranted quickly due to the<br />
Member’s critical health outcome), <strong>Sendero</strong> may deny the request to expedite the review. If this happens,<br />
the provider may intervene on the Member’s behalf and discuss the situation with the Medical Director.<br />
The provider should contact the Medical Director by calling <strong>Health</strong> Services at the number shown on this<br />
page.<br />
State Fair Hearing Information<br />
• Can I ask for a State Fair Hearing?<br />
If you, as the Member of the health plan, disagree with the health plan’s decision, you have the right to ask<br />
for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling<br />
them the name of the person you want representing you. A provider may be your representative. You or<br />
your representative must ask for the fair hearing within 90 days of the date on the health plan’s letter that<br />
tells of the decision you are challenging. If you do not ask for the fair hearing within 90 days, you may lose<br />
your right to a fair hearing. To ask for a fair hearing, you or your representative should either call <strong>Health</strong><br />
Services at the number on the bottom of this page or send a letter to the health plan at:<br />
<strong>Sendero</strong> <strong>Health</strong> <strong>Plans</strong><br />
ATTN: Complaint/Appeal Department<br />
Suite 510<br />
2028 E Ben White Blvd<br />
Austin TX 78741<br />
If you ask for a fair hearing within 10 days from the time you get the hearing notice from the health plan,<br />
you have the right to keep getting the service(s) the health plan denied, at least until the final hearing<br />
decision is made. If you do not request a fair hearing within 10 days from the time you get the hearing<br />
notice, the service the health plan denied will be stopped.<br />
<strong>Sendero</strong> Customer Services 1-855-526-7388 Network Management 1-855-895-0475<br />
<strong>Health</strong> Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)