ancillary/specialty/lab fax: 512 -901 -9724 or phone: 1 ... 2016 winter... · medicine specialist...

NM-IDCNEWS1216

PROVIDER AND PRACTITIONER ANNUAL REMINDER

Sendero Health Plans would like to inform you about our website www.senderohealth.com. We include information about many topics of interest on our website. You can view and/or download information about the following topics on the website. Information about Sendero’s Quality Improvement Program including goals, processes and

outcomes as related to care and service. The process for facility staff, including discharge planners, to refer members to case

management. The process for practitioners to refer members to case management. The process to refer members to disease management. Information about disease management programs, including how to use the services and

how Sendero works with a practitioner’s patients in the program. Sendero’s policy prohibiting financial incentives for utilization management decision-makers. Information about how to obtain or view copies of Sendero’s adopted clinical practice

guidelines and preventive health guidelines, including those for:

Community Care Collaborative Hypertension Protocol (Version 1.2_8/25/2015) Community Care Collaborative Heart Failure Protocol (Version 1.0_6/11/2014) Diabetes Clinical Guidelines for Children and Adults: TX Diabetes Council (2004 -2016) Community Care Collaborative Type 2 Diabetes Mellitus Protocol (Version 1.0_6/11/2014) National Heart Lung Blood Institute (NHLBI) Asthma Care Guidelines (2007) Centers for Disease Control and Prevention: Immunization Schedules for Birth – 18 Years

(2016) Centers for Disease Control and Prevention: Immunization Schedule for Adults Aged 19

Years and Older (2016) Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric

Health Care (2016) for CHIP & IdealCare Agency for Healthcare Research and Quality and U.S. Preventive Services Task Force: Guide

to Clinical Preventive Services: Birth - 0ver 65 (2014) Institute for Clinical Systems Improvement: Preventive Services for Children and

Adolescents (9/2013) Institute for Clinical Systems Improvement: Routine Prenatal Care (7/2012) Beacon Health Options: Adolescent Depression (2012) based on AACAP Practice Guideline Beacon Health Options: Attention Deficit Hyperactivity Disorder based on AACAP Practice

Guideline Beacon Health Options: Depression Management (2013) based on APA Practice Guideline

Information about Sendero’s medical necessity criteria, including how to obtain or view a

copy. Information about the availability of staff to answer questions about UM issues. The toll-free number to contact staff regarding UM issues. The availability of TDD/TTY services for members. Information about how members may obtain language assistance to discuss UM issues. Information about Sendero’s pharmaceutical management procedures including our drug list

along with restrictions and preferences; how to use pharmaceutical management procedures; an explanation of limits and quotas; how practitioners can provide information to

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Ancillary/Specialty/Lab Services

• Chiropractic care > 8 visits • Renal Dialysis • All hospice admissions • All Diagnostic Genetic

Testing • Tumor marker laboratory

tests

DME/Orthotics/Prosthetics • DME (rental or purchase)

and medical supplies >$500 per item

• Continuous Passive Movement (CPM) Machine

• Breast Pumps >$250, limited one per member

• Wound VACs • Orthotics or Prosthetics

devices purchase price >$250 per item

• Hearing Aids • Amino Acid-based

Elemental Formulas or Formula for Treatment of Heritable Diseases, or any canned nutritional.

• CPAP/BiPAP machines

Radiology • CT/CTA Scans, MRIs &

MRAs not provided in an inpatient or Emergency Room setting

• PET Scans/SPECT scans • Radiological procedures

that require admission for observation

• OB ultrasounds >2 unless done by Maternal-Fetal Medicine specialist (MFM)

• No authorization required for high-risk pregnancy ultrasounds unless NOT done by a Maternal Fetal Medicine Specialist (MFM)

Home Health • Skilled nursing visits

(Excluding initial assessment evaluation)

• PT, ST or OT (excluding initial evaluation)

• Infusion therapy • Private duty nursing is NOT

a covered benefit • Home Health Services (60

visits per year)

Other Services

• New and Emerging Technologies or any Treatment, Drug or Device not Approved by the FDA may be Determined to be Experimental or Investigational or not Medically Necessary

Out of Network or Out of Area Services All out of network or out of area, including but not

limited to, inpatient, outpatient hospital

admissions, surgeries, procedures, refer- rals, evaluations, specialty services, prescriptions and/ or treatments are

excluded from coverage unless prior authorized.

Transplants

• All Transplant Services • All organ & tissue

transplants

ONLINE PROVIDER PORTAL Sendero Health Plans is pleased to announce that our new web portal to view eligibility and claims status for IdealCare Dates of Service 1/1/2017-current is now live! Not registered? Please visit https://providerportal.senderohealth.com and click on “REGISTER” to get signed up.

CVI

PRSRT. STD.

U.S. POSTAGE

PAIDSAN ANTONIO,TX

PERMIT #1517

FIRST-CLASS MAIL

U.S. POSTAGE

PAIDSAN ANTONIO, TX

PERMIT NO. 1517

PRST FIRST-CLASS

U.S. POSTAGE

PAIDSAN ANTONIO, TX

PERMIT NO. 1517

PRSRT. STD.

U.S. POSTAGE

PAIDSAN ANTONIO,TX

PERMIT #1517

FIRST-CLASS MAIL

U.S. POSTAGE

PAIDSAN ANTONIO, TX

PERMIT NO. 1517

PRST FIRST-CLASS

U.S. POSTAGE

PAIDSAN ANTONIO, TX

PERMIT NO. 1517

NONPROFIT ORG

U.S. POSTAGE

PAIDSAN ANTONIO, TX

PERMIT NO. 1517

2028 East Ben White Blvd.Suite 400Austin, TX 78741

PROVIDER AND PRACTITIONER ANNUAL REMINDER

PROVIDER UPDATE December 2016

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FAX: 512-901-9724 or PHONE: 1-855-297-9191

Requests should be submitted no less than five (5) business days prior to start of service.

All services are subject to eligibility at the time of service, and benefit limitations

or exclusions.

The following services must be authorized before rendering the service unless otherwise noted: PRIOR AUTHORIZATION LIST

Inpatient/Rehabilitation/ LTAC / Skilled Nursing Facility Services • Authorization of all

admissions to facilities is required, including: Hospital, Rehabilitation Facility, Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTACH), inpatient hospice, or Matern i t y and newborn s ta ys tha t exceed two days for vaginal delivery or four days for Cesarean section delivery

• Facility is responsible for admission notification to Sendero

• Breast Cancer Treatment that exceeds 48 hours following mastectomy or exceeds 24 hours following lymph node dissection

Behavioral Health Services/ Substance Use Disorder Services For prior authorization, benefits, eligibility or other questions, contact Beacon at1-855-765-9696, 24 hours a day, 7 days a week. For Medical anesthesia for electro-convulsive therapy (ECT) obtain authorization from Sendero Health Plans

Surgeries/Procedures (Inpatient or Outpatient) • Circumcision

>1 year of age • Cochlear Implants • Hyperbaric treatment • Accidental Dental Services

• Dental Anesthesia, orthognathic and other oral surgery procedures related to accident or trauma

• TMJ Surgery • Robotic Radiosurgery

(cyber knife and others) • Proton Beam therapies • Cosmetic, Reconstructive

or Plastic Surgery • Implantable Pumps and

Devices over $500 • Treatment for Varicose

Veins • Vagal Nerve Stimulators • Hysterectomy • Nasal Septal

Reconstructions or Revision • Joint Replacement Surgery • Spine Procedures (i.e.

discectomy and decompression)

• Surgery for Obstructive Sleep Apnea

• Balloon Sinuplasty • Umbilical Hernia Surgery

if under age 5 • Osteochondral allograft or

autologous chondrocyte • Anesthesia for

upper/lower GI endoscopic procedures

Outpatient Services/ Treatment • Injectable drugs

>$500 AWP • Sleep Studies/Sleep labs • TMJ treatment • Synagis • PT, ST or OT

(including initial evaluation for ST)

• Treatment for Acquired Brain Injury

• Treatment for Autism Spectrum Disorder

• Biofeedback • GI tract imaging by

Capsule Endoscopy • Pain management

procedures including but not limited to, external or implanted infusion pumps or stimulator devices, epidural steroid injections, and trigger point injections

• Wound care services, including referral to wound care centers, use of wound vacuum devices and specialized wound dressings

• Allergy Testing & Injections

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IdealCare

Do you NEED CARE after your

doctor’s office is closed?

Sendero has AFTER HOUR care

for you!

A list of SENDERO DOCTORS that

provide after hour care is on the back

of this card.

If you have questions about your

health you can call the 24 hour

Nurse Advice Line toll-free

at any time.

CALL toll-free LLAME gratis al

1-855-880-7019¿Necesita que lo atiendan después

de que cerró el consultorio de

su médico?

¡Sendero tiene atención DESPUÉS

DE HORARIO para usted!

En la parte de atrás encontrará

una lista de los DOCTORES DE

SENDERO que atienden después de

horario normal de consulta.

Si tiene preguntas acerca de su

salud puede llamar gratis a cualquier

hora para consultar con la línea de

enfermeros que atiende las 24 horas.

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visits per year)

Other Services






Transplants


transplants


Transportation

Non-emergent ground ambulance services, including facility to facility transportAll Air Transport Services

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Other Services






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transplants


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support an exception request; and Sendero’s processes for generic substitution, therapeutic interchange, and step-therapy.

A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.

Sendero’s member rights and responsibilities statement. If you have any questions about accessing our website or if you would like more information, please call the Network Management Department at 1-855-895-0475. The most recent information about Sendero and our services is always available on our website.

IDEALCARE CLAIMS SUBMISSION NOTICE Member Identification Number Format Change

Beginning 1/1/2017, the number of digits in the suffix of each IdealCare member ID number will be shortened by one digit, going from 000 to 00. Claims Dates of Service 1/1/14 -12/31/16:

Subscriber -0001234567-000 Spouse -0001234567-001 Dependent -0001234567-002

Claims Dates of Service 1/1/17 -future:

Subscriber -0001234567-00 Spouse -0001234567-01 Dependent -0001234567-02

Notice to IDEALCARE Providers - Claims Administration Changes

WHAT IS CHANGING? Sendero will transition claims processing and customer service for IdealCare providers effective 1/1/2017. This change applies to Sendero IdealCare only. WHAT IS NOT CHANGING? If you are currently a Sendero STAR/CHIP provider, continue to use the same claim process for submission of your STAR/CHIP claims. Sendero STAR/CHIP electronic claims will still be submitted using EDI Vendor ID 36426. Sendero STAR/CHIP paper claims and appeals will still be submitted to PO BOX 3869, Corpus Christi TX 78463. Sendero STAR/CHIP Customer Service will still be 1-855-526-7388.

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NEW IDEALCARE MEMBER ID CARDS EFFECTIVE 1/1/17

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NEW IDEALCARE MEMBER ID CARDS EFFECTIVE 1/1/17

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Provider Communication with Members Notice Sendero shall not impose restrictions upon Provider’s free communication with Members about Member’s medical conditions, treatment options or their costs, referral policies, and other managed care policies, including financial incentives or arrangements.

Network Reminder – Use of Modifier 25 Sendero will accept modifier 25 codes when submitted in accordance with the following requirements:

• Modifier 25 is used on a valid CPT or HCPCS procedure code to indicate that the identified service was provided as a distinctly separate service from other similar services furnished on the same date of service.

EXAMPLE: Providing an age-appropriate health screening on the same day as a sick visit.

Sick Visit - Select the appropriate E&M Office Visit Code.

Preventive Screen - Select the age-appropriate preventive E&M Code and affix the 25 modifier.

• Providers may use the modifier 25 when billing an E&M code with another significant procedure on the same day. The modifier 25 should be affixed to the E&M code only. The medical record should clearly support the significance and distinctiveness of the associated procedure.

• The modifier 25 may also be used to bill a preventive health screen, or Texas Health Steps medical checkup, performed on the same day as a sick visit. The modifier 25 should be affixed to the preventive screen code.

The Sendero Fraud, Waste and Abuse (FWA) special investigative unit monitors modifier 25 billings. Occasional chart audits are performed to comply with our FWA program requirements.

PRIOR AUTHORIZATION LIST EFFECTIVE 2/1/2017

Effective 2/1/2017 Sendero Health Plans has made changes to the IdealCare Prior Authorization List. Please review all sections below for any changes that may affect your practice.

EFFECTIVE 2/1/2017

Admission notification and Prior Authorization requests can be submitted: ONLINE:

https://providerportal.senderohealth.com

NM-IDCNEWS1216

HOW WILL THIS AFFECT IDEALCARE PROVIDERS? IdealCare claims with dates of service 12/31/2016 and before:

Continue submitting electronic claims to Sendero IdealCare using EDI Vendor ID 36426. Continue to submit IdealCare paper claims and appeals to :

Sendero Health Plans P.O. BOX 3869 Corpus Christi, TX 78463

For claims customer service and eligibility verification, call Sendero’s IdealCare Customer Service at 1-888-643-3251.

IdealCare claims with dates of services 1/1/2017 and after:

Submit electronic claims to Sendero IdealCare using the new EDI Vendor ID 11440.

Sendero Health Plans P.O. BOX 301425 Houston, TX 77230 • For claims customer service and eligibility verification, call the new Sendero IdealCare Customer Service at 1-844-800-4693.

Sendero IdealCare will no longer accept electronic claims through EDI Vendor ID 36426 or paper claims/appeals at PO BOX 3869, Corpus Christi TX 78463 for claims with DOS 1/1/2017 and after.

Future updates related to the transition will be posted to the IdealCare Provider News page here: https://senderohealth.com/idealcareeng/pnews.html We appreciate your patience through this transition. Should you have any questions, please direct them to [email protected]

Claims must be submited through Relay Health.

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IDEALCARE CLAIMS SUBMISSION NOTICEMember Identification Number Format Change

Notice to IDEALCARE Providers - ClaimsAdministration Changes

HOW WILL THIS AFFECT IDEALCARE PROVIDERS?

NEW IDEALCARE MEMBER ID CARDSEFFECTIVE 1/1/17

Provider Communication with Members Notice

Network Reminder - Use of Modifier 25

PRIOR AUTHORIZATION LIST EFFECTIVE 2/1/2017

ancillary/specialty/lab fax: 512 -901 -9724 or phone: 1 ... 2016 winter... · medicine specialist...

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