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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. |
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 8/15/2023
Forms
Effective 6/15/2021
The following forms are required to be completed when submitting prior authorization requests for the medications listed below:
Fax Form Actemra
Fax Form Cimzia
Fax Form Enbrel
Fax Form Entyvio
Fax Form Humira
Fax Form Ilumya
Fax Form Infliximab
Fax Form Kevzara
Fax Form Orencia
Fax Form Rituximab
Fax Form Siliq
Fax Form Simponi
Fax Form Skyrizi
Fax Form Stelara
Fax Form Taltz
Fax Form Tremfya
Fax Form Tysabri
Claim Reconsideration/Appeal Request Form – 2019 and after
Claim Reconsideration/Appeal Request Form – 2018 and prior
Pregnancy Notification Form
Prior Authorization Form
DME Prior Authorization Required Supporting Documentation
Provider Information Change Form (PIF)
EFT Form – Claim dates of service 1/1/19 and after
Provider Complaint Form
Universal Step Therapy Form
Attention: This website is operated by Sendero Health Plan 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.