Frequently Asked Questions (FAQS)
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If you receive care at an in-network hospital there is a possibility that some of the hospital-based providers are not in-network. Some examples of those providers are anesthesiologist, radiologist, pathologist, an emergency department physician, a neonatologist, an assistant surgeon and/or other providers. These providers can bill you for the difference between IdealCare’s allowed amount and the providers billed charge; this is called balance billing.
Unless Preauthorized or part of covered Emergency Care, Out-of-Network Benefits are considered Excluded Services. You are responsible for the full cost of Excluded Services. Excluded Services do not count toward your Copayment Amounts. If Medically Necessary covered services are not available through an In-Network Provider, your Primary Care Provider (PCP) may request a Preauthorization for you to see an Out-of-Network Provider. If you receive a Preauthorization to see an Out-of-Network Provider, Sendero will fully reimburse the Out-of-Network Provider at the usual and customary rate or at an agreed upon rate. When an Out-Of-Network Provider is Pre-authorized as described above, you are responsible for Copayments as if the Provider were an In-Network Provider.
IdealCare provides members with a grace period of three (3) consecutive months if the member is receiving an Advance Premium Tax Credit (APTC) and has paid at least one full month’s premium during the benefit year. Members that are not receiving an APTC only have a 30 or 31 day grace period.
IdealCare will pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend claims for services rendered to the member in the second and third months of the grace period.
If you are not happy with the decision, you may file an appeal by phone or by mail. You may also request an appeal if IdealCare denied payment of services in whole or in part. Send in the appeal form or call us at toll-free at 1-888-6-IDEAL-1 /1-888-643-3251. If you appeal by phone, you or your representative will need to send us a written signed appeal. You do not need to do this if an Expedited Appeal is requested.
A letter will be mailed to you within 5 working days to tell you we received your appeal and we will mail you our decision within 30 calendar days. If IdealCare needs more information to process your appeal, we will notify you of what is needed within the appeal acknowledgement letter. For life threatening care Concerns or hospital admissions, you may request an Expedited Appeal.
To ensure that claims are not retroactively denied, make sure premiums are paid and up-to-date. Make sure that services received that require authorization receive that authorization. Make sure that services are received from in network providers or services from out-of-network providers have been pre-authorized.
The availability of benefits is subject to other requirements of IdealCare, such as medical necessity, limitations and exclusions, payment of premium, and eligibility at the time care and services are provided. IdealCare’s preauthorization program uses written, medically acceptable screening criteria and review procedures that are established and periodically updated with involvement from network providers.
Sendero will notify your PCP or submitting provider of your approval or denial of the prior-authorization request no later than the third day after the date the request was received. If the preauthorization request is for concurrent hospitalization care, Sendero will notify your PCP or submitting provider within 24 hours after the request is received. If the preauthorization is for post-stabilization treatment or life- threatening conditions, Sendero will provide notification to your PCP or submitting provider no later than one hour after the request was received. If Sendero denies the service(s) we will provide written notification within three working days from the telephone or electronic transmission of the adverse determination. If the circumstance involves post-stabilization treatment or life-threatening conditions Sendero will provide a response for the proposed services requested within the time appropriate to the circumstance relating to the delivery of the services and the condition of the member, but in no case to exceed one hour from receipt of the request.
For further information regarding services that require Prior Authorization, Refer to the Explanation of Coverage (EOC) document specific to your plan. The EOC can be found on the IdealCare website by clicking the “Members” Tab, then “Member Benefits”.
The EOC can be found on the IdealCare website by clicking the “Members” Tab, then “Member Benefits”. Additionally, a copy of the EOC can be mailed to the member upon request. To Request a copy of the EOC, please call 1-888-6-IDEAL-1 / 1-888-643-3251 or write to:
IdealCare Health Plans/ IdealCare
2028 E. Ben White Blvd., Suite 400
Austin, TX 78741
If you have any questions regarding the EOC or the information contained within, please contact the customer service line at 1-888-6-IDEAL-1 / 1-888-643-3251.
If you need TDD/TTY services, just call 1-800-855-2880.
We understand how important it is that we make the right decisions about approving coverage for your care. We take this responsibility seriously. When making decisions about approving coverage, we adhere to the following rules:
• Our decisions are based only on the appropriateness of the care and service being requested and whether or not it is a covered benefit.
• We do not reward practitioners or other individuals in any way for issuing denials of coverage.
• We have no incentives for decision-makers that would encourage them to make decisions that would result in you receiving less care that you need. Sendero expressly prohibits these kinds of incentives.
Sendero has a committee of physicians and pharmacists that decide about our medication procedures. They develop our formulary which is a list of the drugs that we prefer our physicians to prescribe. We have a network of pharmacies where you can get your prescription filled. You may obtain the most current information about the drugs we cover by looking at our formulary by clicking here or by calling Customer Services at 1-888-643-3251.
Our team of physicians and pharmacists reviews the available drugs and selects the ones that they believe are the best for our members. This list of our preferred drugs is the formulary. It includes generic and brand name drugs that we believe are the most appropriate, safe and effective drugs for our members. We review the formulary often to be sure it is current. From time to time, we add new drugs and we remove others. We also have different levels of payments for drugs called cost-sharing tiers.
There is little difference between a brand name drug and the generic version. Generic drugs have the same ingredients as brand name drugs. They are usually a different color and shape. Generic drugs are not as expensive as brand name drugs. Your pharmacy will fill your prescription with a generic drug if it is available. Generic medications are as safe and effective as their brand name counterparts and are usually less expensive. If your doctor does not want a generic substitution, he or she must contact us and tell us the reason. If we do not approve the request, you and/or your doctor will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you or your doctor our decision.
You can review our online formulary by clicking here or by calling Customer Services to check on the coverage for a specific drug. As a member, if the drug you are taking is not listed in our formulary you may ask that we cover the drug. This is called an exception request. Your physician will need to tell us the reasons why he or she believes we should make an exception to our formulary.
For some drugs, our approval is required. This is called prior authorization. If your physician decides that you should take a drug in this group, he or she will contact us to receive authorization before giving you a prescription for the drug.
Your provider must complete a prior authorization form and send it to us so that a decision about coverage can be reached. After the request is reviewed, you and/or your doctor will be informed of our decision. If we approve the drug, you may obtain it from a participating pharmacy. If we do not approve the request, you and/or your doctor will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you our decision.
Some drugs require step therapy. This means that you must try a first step drug before the second step drug will be covered. Usually generic drugs are in the first step.
We encourage safe use of drugs by setting a maximum quantity per month for some drugs. These quantity limits are based on the Food and Drug Administration (FDA) guidelines and the manufacturer’s recommendations. There are circumstances that warrant exceptions to these limits. Your physician can request an exception by contacting us and telling us the reason for the exception. We will inform you about our decision. If we do not approve the request for an exception to the quantity limits, we will tell your physician how to appeal the decision.
You may be asked to take a drug that is chemically different from the drug originally prescribed. This different drug will have the same therapeutic purpose and will be used for the same FDA approved conditions. This is called Therapeutic Interchange. The pharmacist or your prescriber may ask you to take this drug and will explain the reasons why he or she believes this is a better drug choice for you. You do not have to agree. If you do not agree, your original drug prescription will be filled.
For more information about our pharmacy procedures and to see if a drug is included in our formulary, click here, the formulary will tell you about:
Any other requirements, restrictions, limitations, or incentives that apply to the use of certain drugs.
If you get sick when you are out of town or traveling call IdealCare Customer Service toll-free at 1-888-643-3251. We will help you get care.
If you need emergency services while traveling, go to a nearby hospital, and then call us 1-888-643-3251. When you or your covered family member will be temporarily away from home, you should contact your PCP ahead of time to schedule appointments or obtain prescriptions to last for the duration of your stay. Non-emergency services are not covered by IdealCare when you are out of the IdealCare service area. If you receive non-emergency services out of the service area you will be responsible to pay for the balance due to the facility or provider.
If you need to speak to a Customer Service Representative in regards to your benefits, access to care, or any other questions or concerns, we have bilingual Representatives that can help you. Our Representatives speak English and Spanish. We also offer over the phone interpreters in other languages. When you call us, you can ask to talk to someone in the language you speak. We have translation services available. The services are free. If you need help understanding your benefits or how to get care or services please call us.
If you need face-to-face interpreter assistance for your provider’s appointments, IdealCare Customer Service toll-free at 1-888-643-3251. For face-to-face interpretation you will have to call at least 48 hours in advance of your appointment.
Most providers will file claims for you. If your provider does not file claims for you, please submit an itemized bill or receipt within 95 days of the last day on which you received services. No payment will be made on any claim that we receive more than one year after the last day on which you received services. If you have any questions on how t to file a claim please call Customer Service toll-free at 1-888-643-3251.
Send your claim to:
IdealCare by Sendero Health Plans
P.O. Box 3869
Corpus Christi, TX 78463
If you choose to receive medical treatment from an out-of-network provider or at an out-of-network facility, or you receive non-emergency treatment in an emergency room, urgent care centers, or other facilities without authorization from Sendero, you will be responsible for the bill(s). If you receive Emergency Services from an out-of-network facility you will be responsible for any balance of billed services not paid by Sendero. If you receive a bill for laboratory work or another service, which should have been sent to Sendero, contact Customer Service and they will assist you. Customer Service can also assist you if you have paid for services which you believe should be reimbursed.
Once you have chosen an IdealCare Plan, your next choice is to select a provider who will provide the majority of health care services to you and your covered family members. Your primary care provider (PCP) will be the one you call when you need medical advice, when you are sick and when you need preventive care such as immunizations. Each member may select his or her own PCP. You will select a PCP from the IdealCare Plan’s network of family or general providers, internists and pediatricians. The selection of a PCP is crucial for immediate access to acute and preventative care.
For a list of Sendero providers that provide services to IdealCare Plan members, visit our website at www.senderohealth.com/idealcarenetwork. You can also call our Customer Service for assistance toll-free at 1-888-643-3251. Your PCP is your personal provider who will provide and/or coordinate all aspects of your medical care and oversee your course of treatment to ensure that proper care is maintained. Sendero uses standardized processes to evaluate and approve providers for inclusion in the Sendero network. In-network providers are reviewed on a regular basis to ensure they continue to meet Sendero’s standards. Your PCP is your main source of medical care and your link to specialists, hospitals and other providers.
Please assist your PCP by:
• Requesting that your prior medical records be transferred to your PCP’s office.
• Presenting your IdealCare member ID card whenever you receive medical services.
• Paying the provider the applicable deductible(s), copayment(s), and coinsurance at the time of service.
• Contacting your PCP as soon as possible after a medical emergency so he or she can arrange for follow-up care.
• Obtaining a referral from your PCP before seeking non-emergency specialty medical care, except when accessing care from an obstetrician/gynecologist (OB/GYN) or behavioral health provider.
Your PCP is available, directly or through arrangements for coverage with other providers, 24 hours a day, 7 days a week. If you are admitted to an inpatient facility, a provider other than your PCP may direct and oversee your care. If you have a chronic, disabling or life-threatening condition, you may request to use a specialty care provider as your PCP. For a specialty care provider to be named as your PCP, he or she must meet all Sendero PCP requirements and be willing to accept the responsibility of coordinating all of your health care needs. If you want to request a specialty care provider as your PCP, call Customer Service to make the change request.
The IdealCare Plan covers a full range of specialty services. If your PCP determines that your condition requires treatment by a specialist, he or she will refer you to the appropriate in-network specialist.
NOTE: You are not required to obtain a referral from your PCP to access care from an OB/GYN or behavioral health provider within the IdealCare Plan network.
For a list of specialty care providers in the IdealCare Plan network, visit our website at www.senderohealth.com/idealcarenetwork. This list is updated every two weeks. You may also call Customer Service for the most current network provider information toll-free at 1-888-643-3251.
Your PCP or specialist will arrange hospital services for you if you need to be hospitalized.
Emergency care includes those health care services you receive in a hospital emergency room or comparable facility to evaluate and stabilize certain medical conditions, including behavioral health conditions. These conditions are of a recent onset and severity (such as severe pain) that would lead a person with average knowledge of medicine and health to believe that the person’s condition, sickness or injury is such that failure to get immediate medical care could cause the following:
• Placing the patient’s health in serious jeopardy
• Serious impairment of bodily functions
• Serious dysfunction of any bodily organ or part
• Serious disfigurement
• In the case of a pregnant woman, serious jeopardy to the health of the fetus
In addition, here is a limited list of situations that would also be considered medical emergencies. If you believe you have a medical emergency, go to the ER or call 9-1-1:
• Apparent heart attack
• Loss of consciousness
• Chest pain with symptoms of heart attack
• Severe bleeding
• Severe abdominal pain of sudden onset
• Severe injuries or trauma
• Shock from sudden illness or injury
• Difficulty in breathing, such as in a severe asthma attack
If you have any questions regarding whether a situation is an emergency, please contact your PCP who will direct you based on your symptoms. You can also call Sendero nurse advice line toll-free at 1-855-880-7019 24/7 to get direction based on your symptoms.
Emergency care services are covered anywhere, in-network and out-of-network, 24-hours a day. If an emergency occurs, you should go to the nearest emergency medical facility. Necessary emergency care services will be provided to you, including treatment and stabilization of a medical condition and any medical screening examination or other evaluation required by state or federal law which is necessary to determine if an emergency exists.
If, after medical screening, emergency treatment is determined not necessary, you must contact your PCP to arrange any non-emergency care needed. If you choose to use the emergency room for non-emergency treatment, you will be responsible for all billed charges. You must contact your PCP before receiving follow-up care, even if you are referred to a specialty care provider from the emergency room or advised to return to the emergency room by the treating provider. You or someone acting on your behalf should contact your PCP within 24-hours or as soon as reasonably possible, so that he or she may arrange for follow-up care.
If you seek non-emergency care at an out-of-network facility you may be balanced billed for additional charges from the hospital.
If you have concerns about or are unhappy about the services or care you have received from IdealCare, an IdealCare provider or any aspect of your health plan benefits, please call us. Call IdealCare’s Customer Service toll-free at 1-888-643-3251. A full investigation of your complaint will be completed and our decisions will be forwarded to you in writing within 30 calendar days from receipt of your verbal or written complaints and/or complaint form. The complaint form can be found on our website at www.senderohealth.com or by calling our Customer Service toll-free at 1-888-643-3251.
IdealCare will not discriminate or take punitive action against a member or a member’s representative for making a complaint, an Appeal, or an Expedited Appeal. IdealCare will not engage in retaliatory action, including refusal to renew or cancellation of coverage, against a member because the member or a person acting on behalf of the member has filed a complaint against IdealCare or appealed a decision of IdealCare.
IdealCare will not engage in retaliatory action, including refusal to renew or termination of a contract, against a provider because the provider has, on behalf of a member, reasonably filed a complaint against IdealCare or appealed a decision of IdealCare.
At any time you may file a complaint with the Texas Department of Insurance (TDI) by writing or calling:
Texas Department of Insurance (TDI)
P.O. Box 149104
Austin, Texas 78714-9104
You may appeal a decision that adversely affects coverage, benefits or your relationship with Sendero Health Plans. If you are not happy with a decision we make, you may file an appeal by phone or mail. You may call us toll-free at 1-888-6-IDEAL-1 /1-888-643-3251. If you need language assistance to file an appeal, let us know and we will provide help for you to file an appeal. You may send a written appeal to:
IdealCare by Sendero Health Plans
2028 E. Ben White Blvd., Suite 400
Austin, TX 78748
DENIALS OR LIMITATIONS OF PROVIDER’S REQUEST FOR COVERED SERVICES
Sendero may deny health care services that are not considered to be medically necessary. If Sendero denies healthcare services, a letter will be mailed to you with the reason for the denial and an appeal form.
If you are not happy with the decision, you may file an appeal by phone or by mail. You may also request an appeal if Sendero denied payment of services in whole or in part. Send in the appeal form or call us at toll-free at 1-888-643-3251. If you appeal by phone, you or your representative will need to send us a written signed appeal. You do not need to do this if an Expedited Appeal is requested.
Within 5 business days of receipt of an oral Complaint, Sendero will send you a letter acknowledging the Complaint. The acknowledgment letter will contain a description of Sendero’s Complaint procedures and time frames as well as a Complaint form for you to fill out and return to Sendero. This form must be returned in order to receive prompt resolution of your complaint. Your Complaint will be investigated and Sendero will respond to you within 30 calendar days from the receipt of the completed Complaint form.
Within 5 business days of receipt of a written Complaint, Sendero will send you a letter acknowledging the Complaint; it will include a description of Sendero’s Complaint procedures and time frames. Your Complaint will be investigated and Sendero will respond to you within 30 calendar days from the receipt of the written Complaint.
Your Complaint response letter will explain the resolution of the Complaint; provide specific medical and contractual reasons for the resolution, specify the specialization of any Provider that consulted on the Complaint, and include a complete description of the process to Appeal, including the deadlines for the Appeals process and deadlines for the final decision of the Appeal.
If you are not satisfied with the resolution to your Complaint, you may initiate a Complaint Appeal. The Complaint Appeal process provides for you to appear in person before a Complaint Appeal panel or to address a written Appeal to the Complaint Appeal panel.
Sendero will send an acknowledgement letter to you within 5 business days of receipt of a written Complaint Appeal request. The acknowledgement letter will detail your rights and outline the Complaint Appeal process. The Complaint Appeal panel will be composed of an equal number of Sendero staff, Providers, and enrollees. Panel members may not have been previously involved in the disputed decision. The Complaint Appeal Panel will deliberate on the Complaint Appeal and advise Sendero on the resolution of the Complaint Appeal.
The Complaint Appeal resolution letter will include a notice of the final decision and include the specific medical determination, clinical basis, and contractual criteria used as the basis of the Complaint Appeal resolution. The Complaint Appeal resolution will be completed within 30 business days from the receipt of the written Complaint Appeal request.
If you are not satisfied with the resolution of your Complaint or Complaint Appeal, you can also complain to the Texas Department of Insurance by calling toll-free to 1-800-252-3439. If you would like to make your request in writing, send it to:
Texas Department of Insurance Consumer Protection
Section (MC 111-1A)
P.O. Box 149091
Austin, Texas 78714-9091
What is Obamacare/The Affordable Care Act?
Obamacare, officially known as The Affordable Care Act, was signed into law on March 23, 2010. The law significantly reforms our health care system and aims to ensure affordable health coverage is available to those who don't receive it through an employer. The law mandates that Americans must purchase health insurance, but some people will qualify to get help paying for it if they meet certain criteria. The majority of the reforms begin in 2014, though it won't be completely rolled out until 2022.