Yes, you may be liable for services received from an out-of-network provider. You are enrolled in a Health Maintenance Organization (HMO) which is a type of managed care health plan where members choose their physician from a list of in-network providers.

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.

Grace Period is a time period in which an overdue premium can be paid after the due date and the member is able retain ongoing coverage.

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.

Texas’ Prompt Pay Act requires Sendero to pay clean claims within 30-days of receipt or the date the claim is deemed “clean.” Sendero is responsible for denying or approving claims within the 30-day timeframe.

Claims pending means until a determination can be made, the claim is pended and neither paid nor denied. Sendero does not hold nor pend claims.

A retroactive denial is the reversal of a previously paid claim, through which the member then becomes responsible for payment. IdealCare may deny coverage for health care services that are not covered by your benefit plan. If IdealCare denies healthcare services a letter will be mailed to you with the explanation for the denial with instructions on how to file an appeal.

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 1-844-800-4693. 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.

If you have overpaid for treatment and or a procedure, please contact Customer Service at 1-844-800-4693. We will assist you with contacting the provider to advise them of the overpayment and requesting a refund.

Coordination of Benefits means that the member is covered by another plan and determines which plan pays first. As a Marketplace participant, you need to notify the Exchange if you gain or have access to other coverage, such as a plan offered by an employer. If you have any questions about coordination of benefits, contact Customer Service toll-free at 1-844-800-4693.

Sometimes our members need access to drugs  that are not listed on the plan’s formulary (drug list). These medications are initially reviewed by Sendero through the formulary exception review process. The following people can request a coverage determination:

• An enrollee,
• An enrollee’s prescriber, or
• An enrollee’s representative.

Your doctor may ask us for a coverage determination for you. You can also have a different person, like a family member or friend, make a request for you. That person must be identified as your representative. Call 1-866-333-2757.

Requests need to be submitted to Navitus. You can ask for two kinds of determination:

Standard Request – Are requests that are not urgent. The turnaround time to receive a response to your request is 72-hours from when we receive the request.

Expedited Requests – Urgent is defined as: There is an imminent and serious threat to your health. The turnaround time to receive a response to your request is 24-hours from when we receive the request.

Either of these requests can be made orally or in writing. If you want to submit your request in writing, use the Model Coverage Determination Request Form. You can fill the form out and fax it to 1-855-668-8551 or log in to the member portal and submit the form electronically:

Exception to Coverage form

Instructions on how to fill out the Exception to Coverage form

You may need to send attachments. If so, please fax or mail the form along with whatever you need to include. If you need a hard copy of the form sent to you, call 1-866-333-2757. You may also ask us for a coverage determination orally by phone. To do this, call 1-866-333-2757.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer know as an HHS-Administered Federal External Review Request. We must follow the HHS-Administered Federal External Review decision.

An HHS-Administered Federal External Review may be requested by a member, member’s representative or prescribing provider by mailing, calling, or faxing the request:

HHS-Administered Federal External Review Request form 

Mail To:

MAXIMUS Federal Services

State Appeals East

3750 Monroe Avenue, Suite 705

Pittsford, NY 14534

Toll-free phone: 888-866-6205 ext. 3326

Fax: 888-866-6190

Website: https://www.externalappeal.com/ferpportal/#/requestReviewOnline  

If you believe that waiting for the Independent Review will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you, an individual acting on your behalf or the provider of record may ask for an expedited review by writing or calling MAXIMUS Federal Services, Inc.

MAXIMUS Federal Services

State Appeals East

3750 Monroe Avenue, Suite 705

Pittsford, NY 14534

Toll-free phone: 888-866-6205 ext. 3326

Fax: 888-866-6190

Website: https://www.externalappeal.com/ferpportal/#/requestReviewOnline

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 1-844-800-4693.

Send your claim to:

Sendero Health Plans
Attn: Claims
P.O. Box 759
Austin, TX 78767

You can also email your claim to:
customerservice@senderohealth.com

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.

Click here for a claim form.

An EOB is posted in the member portal once we have processed a claim. Members can access and view EOBs in the Member Portal. You can access Sendero’s Member Portal at https://sendero.healthtrioconnect.com/.

An EOB is a notice that gives you a summary of your prescription and medical costs. The summary tells you how much your provider billed, the approved amount your plan will pay, and how much you have to pay to the provider. If your EOB shows that an item or service is not covered, look for a section that includes notes, comments, footnotes, or remarks to find out the reason why. You may have to look on the next page to find this information.

Contact Sendero if you have any questions about your EOB. You should also contact Sendero for more information if any of your services or items were not covered. Try to save your EOBs. You might need them in the future to prove that certain costs have been covered / paid for. For instance, you may need old EOBs if a provider’s billing department makes a mistake or if you claimed a medical deduction on your taxes.