Providers

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

Post Date	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
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
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
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
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
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
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

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*This amount was announced in June 2022.