PROVIDER MANUAL 2017 - Sendero Health Plans

1 PROVIDER MANUAL 2017 SERVICE AREA: BASTROP, BURNET, CALDWELL, FAYETTE, HAYS, LEE, TRAVIS & WILLIAMSON COUNTIESI mportant phone numbers / n meros telef nicos importantesSENDERO CUSTOMER SERVICES 1-844-800-4693 NETWORK MANAGEMENT 1-855-895-0475 PROVIDER /CUSTOMER SERVICES 1-844-800-4693 Health SERVICES DEPT. 1-855-297-9191 Health SERVICES DEPT. FAX 512-901-9724 Sendero IdealCare PROVIDER MANUAL rev. 02/17 Page 1 of 89 Sendero IdealCare Customer Service 1-844-800-4693 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 512-901-9724) TABLE OF CONTENTS IDEALCARE PRIOR AUTHORIZATION LIST .. 4 INTRODUCTION .. 6 Background of IdealCare by Sendero Health Plans .. 6 Sendero s Philosophy of Business .. 6 Sendero IdealCare s Program Objectives.

2 7 Sendero IdealCare s Material Subcontractors / Other Key Vendors .. 7 Role of Primary Care PROVIDER .. 7 Role of the Specialty Care 8 Role of the Pharmacy .. 8 Network Limitations ( Primary Care Providers, Specialists, OB/GYN) .. 8 GUIDELINES FOR PROVIDERS .. 10 The Role and Responsibilities of the Primary Care PROVIDER .. 10 Who Can Be a Primary Care PROVIDER ? .. 12 OB/GYN Physician .. 12 Other Specialists as Primary Care PROVIDER .. 13 Primary Care PROVIDER Panel of Members .. 15 Primary Care PROVIDER Panel Changes .. 15 Primary Care PROVIDER & Specialist Accessibility and Appointment Standards .. 16 Primary Care PROVIDER Referrals to Other Providers .. 17 Members Right to 18 Responsibilities of 18 Pharmacy PROVIDER Responsibilities .. 20 Credentialing and Responsibilities of Mid-Level Practitioner.

3 20 Medical Records .. 20 Changes in PROVIDER Addresses or Contact Information or Opening of New Office 22 Cultural Sensitivity .. 22 Reporting Fraud, Waste, or Abuse by a PROVIDER or Member .. 23 Termination of PROVIDER Participation .. 23 Member/ PROVIDER Communications .. 25 EMERGENCY SERVICES .. 26 Definitions: Routine, Urgent and Emergent Services .. 26 Prudent Layperson Standards at Sendero IdealCare .. 27 Out of Network Emergency Services .. 27 Emergency Transportation .. 27 Emergency Services Outside the Service Area .. 27 BEHAVIORAL Health SERVICES .. 28 Definition of Behavioral 28 Primary Care PROVIDER Requirements for Behavioral Health .. 28 Sendero IdealCare Behavioral Health Services .. 28 Sendero IdealCare s 24-hour/7 Days a Week Behavioral Health Hotline.

4 29 Covered Behavioral Health Services .. 30 Sendero IdealCare PROVIDER MANUAL rev. 02/17 Page 2 of 89 Sendero IdealCare Customer Service 1-844-800-4693 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 512-901-9724) Referral Authorizations for Behavioral Health Services .. 30 Prior Authorization .. 31 Responsibilities of Behavioral Health Providers .. 31 DSM-IV Coding Requirements .. 31 Laboratory Services for Behavioral Health Providers .. 32 Court-ordered Services and Commitments .. 32 Confidentiality of Behavioral Health Information .. 32 MEDICAL MANAGEMENT .. 33 Utilization Management Program .. 33 Management of Utilization .. 35 Referrals .. 36 Prior Authorization .. 39 Vision Services.

5 40 Transplant Services .. 40 Complex Case Management Program .. 40 Disease Management Programs .. 42 Practice Guidelines .. 42 BILLING AND CLAIMS .. 44 What is a Claim? .. 44 What is a Clean Claim?.. 44 Electronic Claims Submission: ANSI-837 .. 44 Submitting Paper Claims to Sendero 44 Timeliness of 45 Timeliness of Payment .. 45 Coding Requirements: ICD10 and CPT/HCPCS Codes .. 46 E&M Office Visits Billing 46 E&M Consult Billing Requirements .. 46 Emergency Services Claims .. 47 Use of Modifier 25 .. 47 Billing for Assistant Surgeon Services .. 47 Billing for Capitated Services .. 48 Billing for Immunization and Vaccine Services .. 48 Billing for Outpatient Surgery Services .. 48 Billing for Hospital Observation Services .. 49 Coordination of Benefits (COB) Requirements.

6 49 Collecting from or Billing Sendero IdealCare Members for Co-pay Amounts .. 49 Billing Members for Non-covered Services .. 49 Providers Required to Report Credit Balances .. 50 Filing a Reconsideration or Appeal for Non-payment of a Claim .. 50 Claims & Appeals Questions .. 51 Electronic Funds Transfer (EFT) .. 51 Rural Health Clinic Billing Guidelines .. 52 Sendero IDEALCARE QUALITY 53 Sendero IdealCare s Quality Improvement Program (QIP).. 53 Sendero IdealCare PROVIDER MANUAL rev. 02/17 Page 3 of 89 Sendero IdealCare Customer Service 1-844-800-4693 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 512-901-9724) Sendero IdealCare s PROVIDER Quality Measures .. 53 Sendero IdealCare s HEDIS Measurements.

7 54 Sendero IdealCare s Quality Improvement Committee .. 55 How to Get Involved in Sendero IdealCare s Quality Program .. 55 PROVIDER Report 55 Confidentiality .. 55 Focus Studies and Utilization Management reporting requirements .. 56 CREDENTIALING AND RE-CREDENTIALING .. 58 Credentialing and Re-credentialing 58 PROVIDER Site Reviews .. 58 Required Office Policies & Procedures .. 59 Re-Credentialing Requirements .. 60 Practitioner Credentialing Rights .. 61 FRAUD, WASTE OR ABUSE .. 62 APPENDIX A .. 64 Sendero Referral/Authorization Form .. 66 Pregnancy Notification Form .. 68 Specialist Acting as a PCP Request Form .. 69 Complaint Form .. 70 PROVIDER Information Form (PIF).. 71 Electronic Fund Transfer (EFT) .. 73 Electronic Remittance Advice (ERA) .. 74 Member Acknowledgement Statement Form.

8 75 Private Pay Form Agreement .. 76 Sendero IdealCare ID card .. 77 APPENDIX B .. 78 PROVIDER Complaints and Appeals .. 79 APPENDIX C .. 80 Benefits, Covered Services, Limitations and Exclusions .. 81 Member Rights and Responsibilities .. 83 Member Complaints and Appeals .. 84 APPENDIX D .. 87 Preventive Care Guidelines List .. 88 Clinical Practice Guidelines List .. 89 Sendero IdealCare PROVIDER MANUAL rev. 02/17 Page 4 of 89 Sendero IdealCare Customer Service 1-844-800-4693 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 512-901-9724) IdealCare Prior Authorization List EFFECTIVE 02/01/ 2017 Medical benefits and eligibility must be verified prior to requesting authorization. Admission notification and Prior Authorization requests can be submitted: ONLINE: FAX: 512-901-9724 or PHONE: 1-855-297-9191 The following services must be prior-authorized before rendering the service: Sendero IdealCare PROVIDER MANUAL rev.

9 02/17 Page 5 of 89 Sendero IdealCare Customer Service 1-844-800-4693 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 512-901-9724) Sendero IdealCare PROVIDER MANUAL rev. 02/17 Page 6 of 89 Sendero IdealCare Customer Service 1-844-800-4693 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 512-901-9724) Introduction Background of IdealCare by Sendero Health Plans Sendero Health Plans ( Sendero ) is a local non-profit corporation based in Austin, Texas and licensed as a community-based Health Maintenance Organization (HMO) that serves Central Texas. Sendero is sponsored by the Travis County Healthcare District, doing business as Central Health , which is providing organizational and financial resources to enable Sendero Health Plans to become a major player in improving Health care access for people in Central Texas.

10 In January 2014, Sendero became a qualified Health insurance option for consumers in the Travis service area as part of the Affordable Care Act (ACA) which provides for the creation of a Health benefit exchange in each state. State-based Health insurance exchanges, or Marketplaces, are a key component of the ACA and enable consumers to compare a selection of qualified Health insurance options in order to find the plan that best meets their needs and budget. Sendero began providing services to the Marketplace population in Travis and surrounding counties of Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, and Williamson in January 2014 under the plan name IdealCare. Mission Statement Sendero is committed to providing comprehensive healthcare coverage and to arrange for innovative, high quality and cost-effective medical services for Health plan Members within Central Texas.