Providers

Quality Improvement
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Preauthorization
Provider Resources
Provider Notices

The Sendero Health Plans Quality Improvement Program is committed to continuously improving the quality of care and service for Sendero’s members and practitioners. Sendero is accredited by the National Committee of Quality Assurance (NCQA).

Sendero’s Quality Improvement Committee (QIC) reports to the Sendero Board of Directors and is responsible for implementation of the Quality Improvement Program. The QIC, in conjunction with four subcommittees (Provider Advisory, Compliance, Member Advisory, and Delegation Oversight), addresses all aspects of member, practitioner, and organizational quality.

This includes:

●	Implementation of programs that improve member health.
●	Implementation of clinical practice guidelines, preventive health guidelines, medical necessity criteria, and medical, pharmaceutical and behavioral health policies.
●	Evaluation of outsourced and delegated services – claims, vision, pharmacy, behavioral health services, customer service.
●	Evaluation of the effectiveness of quality improvement interventions.
●	Evaluating member and practitioner satisfaction.
●	Maintaining an adequate practitioner and facility network.
●	Monitoring internal and external audits and investigations for the purpose of identifying troublesome issues and deficient areas experienced by the company and implementing corrective and preventive action.
●	Determining the appropriate strategy/approach to promote compliance with the program and detection of any potential violations, such as through hotlines and other fraud reporting mechanisms.

Thank you for your interest in becoming an in-network provider for Sendero Health Plans.

For more information on joining our provider network, please email us at SenderoProviderContracts@senderohealth.com or click here to download a provider interest form.

If you have any questions about joining our network, please call our Network Management team at 1-855-895-0475.

Provider Notification of Changes to Preauthorization List

NOTICE DATE	NOTICE DETAILS
11/02/24	Physician and Provider Notification of Preauthorization List Changes – Effective 01/01/25
09/27/24	Physician and Provider Notification of Preauthorization List Changes – Effective 11/26/24
09/01/24	Physician and Provider Notification of Preauthorization List Changes – Effective 09/01/24
02/02/24	Physician and Provider Notification of Preauthorization List Changes – Effective 04/02/24

Current Preauthorization and Notification Lists

DETAILS
Preauthorization Code Interactive Lookup Tool
Navitus PA Drug List
Health Care Services Requiring Preauthorization
Quick Reference Guide – effective DOS 11/26/2024

* To determine the medical necessity of healthcare services, Sendero uses evidence-based InterQual criteria published by Change Healthcare, supplemented by internal criteria. Because these criteria are proprietary, they are not available for public view. Sendero will provide a copy of the criteria upon request for any specific authorization.

Utilization Review Statistics

DETAILS
2023 Med and BH Denials and Appeals and Auth Totals
2023 Med and BH Denials and Appeals and Auth Summary
2023 RX Prior Auth Denials 1
2023 RX Prior Auth Denials 2
2023 PA Stats Denial Info Summary 1
2023 PA Stats Denial Info Summary 2

Preauthorization Forms

DETAILS
Texas Standard Prior Authorization Request Form
Provider Preauthorization Exemption Correspondence Preference Form
Navitus Step Therapy Form

Policies and Procedures

DETAILS
Prior Authorization Process Description
Physician and Provider Preauthorization Exemptions Policy

Manuals
Provider Manual

Guides
Quick Reference Guide
Provider Portal User Guide

Forms
Claim Reconsideration/Appeal Request Form
Provider Information Change Form (PIF)
EFT Form
Provider Complaint Form

2024 Notices

NOTICE DATE	NOTICE DETAILS
09/19/24	Sendero TPA Transition Provider Notice
06/05/24	Taxonomy Requirement Provider Notice
03/01/24	Change Healthcare Provider Notice
01/08/24	Notice to Physicians and Providers

2023 Notices

NOTICE DATE	NOTICE DETAILS
11/10/23	Provider and Practitioner 2023 Annual Reminder
03/09/23	Billing for Telehealth Therapy Services during the COVID-19 Response – Updated 3/9/2023
01/09/23	Notice to Physicians and Providers

2022 Notices

NOTICE DATE	NOTICE DETAILS
12/19/22	Provider and Practitioner 2022 Annual Reminder
10/31/22	Provider Manual and Preauthorization List Update Notice – Effective 1/1/2023
09/30/22	Provider Manual Update Notice – Effective 10/1/2022
01/31/22	Reminder – Billing Update – National Drug Code Requirements – Effective 7/8/2021
01/10/22	Notice to Physicians and Providers

2021 Notices

NOTICE DATE	NOTICE DETAILS
12/29/21	Provider and Practitioner 2021 Annual Reminder
04/09/21	Billing Update – National Drug Code Requirements – Effective 7/8/2021
04/09/21	Prior Authorization Fax Forms – Effective 6/15/2021
01/25/21	COVID-19 Response – Provider Guidance
01/11/21	Notice to Physicians and Providers

2020 Notices

NOTICE DATE	NOTICE DETAILS
10/30/20	Provider Manual and Prior Authorization List Update Notice – Effective 1/1/2021
10/01/20	2021 SelectCare plan update
07/10/20	Education on Prior Authorization Request Submission
05/28/20	Applied Behavior Analysis Billing Update Notice – Effective 8/26/2020
05/28/20	Prior Authorization List Update Notice – Effective 7/27/2020
02/14/20	Prior Authorization List Update Notice – Effective 4/15/2020
02/10/20	Prior Authorization List Update Notice – Effective 3/1/2020
02/10/20	Home Health Services Billing Update Notice – Effective 3/1/2020
01/29/20	Provider Manual Update Notice – Effective 2/1/2020
01/13/20	Notice to Physicians and Providers

2019 Notices

NOTICE DATE	NOTICE DETAILS
12/12/19	Provider and Practitioner 2019 Annual Reminder
11/01/19	IdealCare Provider Manual Update Notice – Diagnosis code pointer requirements
11/01/19	IdealCare Provider Manual Update Notice – Effective 12/1/2019
10/01/19	Chiropractic Services Billing Update Notice – Effective 11/1/2019
08/30/19	IdealCare Provider Manual Update Notice – Effective 10/1/2019
08/26/19	IdealCare Provider Manual Update Notice – Effective 8/26/2019
06/17/19	IdealCare Provider Manual Update Notice – Effective 6/17/2019
05/01/19	IdealCare Provider Manual Update Notice – Effective 5/1/2019
04/03/19	QW Modifier Update – Effective 5/3/2019
03/01/19	IdealCare Provider Manual and Prior Authorization List Update – Effective 4/1/2019
01/22/19	DME Prior Authorization Required Supporting Documentation – Effective 1/22/2019
01/14/19	Notice to Physicians and Providers

2018 Notices

NOTICE DATE	NOTICE DETAILS
12/27/18	IdealCare Provider Manual Update Notice – Effective 1/1/2019
12/24/18	Registration Information – New Provider Portal effective 1/1/2019
11/30/18	Changes to IdealCare Prior Authorization List – Effective 1/1/2019
11/30/18	IdealCare Electronic Claims Process Update – Effective 1/1/2019
11/09/18	IdealCare Claims and Customer Service Changes – Effective 1/1/19
09/05/18	IdealCare Provider Manual Update Notice – Effective 9/5/2018
08/03/18	Pharmaceutical Management Procedures Notice
08/02/18	Financial Incentives Notice
07/17/18	Medical Necessity Criteria Notice
07/01/18	IdealCare Provider Manual Update Notice – Effective 7/1/2018
07/01/18	Federal External Review Process
06/08/18	IdealCare Provider Manual Update Notice – Effective 6/8/2018
05/01/18	Reminder: IdealCare Reconsiderations & Appeals Process
03/30/18	IdealCare Provider Manual Update – Effective 3/30/2018
03/14/18	Consolidated Credentialing Verification Organization (CVO) presentation
02/20/18	Consolidated Credentialing Verification Organization (CVO) Implementation to begin April 1, 2018

Providers

Resources

New Provider Portal

*This amount was announced in June 2022.