Medical Clinical Practice Guidelines
Hypertension Guidelines for Adults in Primary Care (2017)
Disease Management Practice Guidelines
Texas Diabetes Council – Tool Kit (2017) – Please see documents under A1c Goals
Preventive Health Guidelines
Centers for Disease Control and Prevention Immunization Schedules Birth – 18 Years (2018)
Centers for Disease Control and Prevention Immunization Schedule for Adult 19 Years and Older (2018)
Agency for Healthcare Research and Quality and U.S. Preventive Services Task Force Guide to Clinical Preventive Services: Birth – Over 65 (2014)
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.
Medical Coverage Policies
Medical Coverage Policy EED
Medical Coverage Policy – Nitric Oxide
Medical Coverage Policy – Continuous Glucose Monitoring in Interstitial Fluid
Medical Coverage Policy – Telemedicine Medical Services and Telehealth Services
Manuals
Provider Manual – effective DOS 10/01/2024
Forms
The following forms are required to be completed when submitting prior authorization requests for the medications listed below:
Claim Reconsideration/Appeal Request Form
Pregnancy Notification Form
Prior Authorization Form
Provider Information Change Form (PIF)
EFT Form – Claim dates of service 1/1/19 and after
Provider Complaint Form
Universal Step Therapy Form
Guides
Quick Reference Guide – effective DOS 11/26/2024
Quick Reference Guide – effective DOS 09/01/2024
Provider Notification of Changes to Preauthorization List
2024-09-27 Physician and Provider Notification of Preauthorization List Changes
2024-09-01 Physician and Provider Notification of Preauthorization List Changes
2024-02-02 Physician and Provider Notification of Preauthorization List Changes
Current Preauthorization and Notification Lists
Preauthorization Code Interactive Lookup Tool
Navitus PA Drug List
2024-09-01 Health Care Services Requiring Preauthorization
Quick Reference Guide – effective DOS 11/26/2024
Quick Reference Guide – effective DOS 09/01/2024
Utilization Review Statistics
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
Forms
Prior Authorization Form
Provider Preauthorization Exemption Correspondence Preference Form
Policies and Procedures
Prior Authorization Process Description
Physician and Provider Preauthorization Exemptions Policy
PO Box 759, Austin, TX 78767
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All Rights Reserved.
Attention: This website is operated by Sendero Health Plans and is not the Health Insurance Marketplace® website at HealthCare.gov. This website does not display all Qualified Health Plans (QHPs) available through HealthCare.gov. To see all available QHP options, go to the Health Insurance Marketplace® website at HealthCare.gov. Also, you should visit the Health Insurance Marketplace® website at HealthCare.gov if you want to enroll members of your household in separate QHPs.