Frequently Asked Questions (FAQS)
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Did you know that Sendero offers special programs to help you with your health?
Sendero has many of services to help you become educated about health care conditions, coordinate your care and manage your medical conditions.
We have a special program, called case management, to help coordinate your care and to provide advice on managing your medical conditions. This program is especially useful if you have multiple medical conditions or if you have recently experienced a major challenge to your health.
You will be assigned a care coordinator (clinician). The clinician will help answer questions you might have about your health care or prescriptions, schedule health care appointments for you if you need assistance, tell you about ways to stay healthy and learn to prevent problems and help you arrange other medical services you may need to stay healthy at home.If you would like to be considered for case management, you or someone who helps you can call us at 1-855-826-7388.
What are Disease Management programs and could these programs help me?
Sendero has many services to help you become educated about health care conditions and manage your medical conditions.
We have programs that provide support and education if you have Diabetes or Asthma. These are called Disease Management Programs. We provide information about Diabetes or Asthma and help you with problems you may have with these conditions. We will help you manage these chronic conditions and learn ways to keep yourself healthy if you have Diabetes or Asthma.If you would like to be considered for the Diabetes or Asthma Programs, you or someone who helps you, can call us at 1-855-826-7388.
Who can I contact if I have questions about the decisions made in regards to my medical care and services authorized?
How do I talk with staff about Utilization Management issues, if I am hearing impaired?
How are Utilization Management decisions made?
We understand how important it is that we make the right decisions about approving coverage for your care. We take this responsibility seriously. When making decisions about approving coverage, we adhere to the following rules:
• Our decisions are based only on the appropriateness of the care and service being requested and whether or not it is a covered benefit.
• We do not reward practitioners or other individuals in any way for issuing denials of coverage.
• We have no incentives for decision-makers that would encourage them to make decisions that would result in you receiving less care that you need. Sendero expressly prohibits these kinds of incentives.
What are my health benefits?
What services are not covered?
How to use Your Pharmacy Benefits?
Sendero Health Plans has a committee of physicians that works with Navitus, our PBM, to establish our pharmaceutical management procedures. The Texas Health and Human Services Commission developed a formulary, or preferred drug list, which you can review by clicking here. The formulary includes brand name and generic drugs. When available, generic drugs are used to fill prescriptions unless the practitioner specifies “no substitution”.
There is little difference between a brand name drug and the generic version. Generic drugs have the same ingredients as brand name drugs. They are usually a different color and shape. Generic drugs are not as expensive as brand name drugs. Your pharmacy will fill your prescription with a generic drug if it is available. Generic medications are as safe and effective as their brand name counterparts and are usually less expensive. If your doctor does not want a generic substitution, he or she must contact us and tell us the reason. If we do not approve the request, you and/or your doctor will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you or your doctor our decision.
The formulary is reviewed often to be sure it is current. From time to time, new drugs are added and others are removed. The formulary provides information on quantity limits and prior authorization requirements for covered drugs.
The formulary is reviewed on an ongoing basis. The most up-to-date information can always be found in the online formulary. A summary of changes can be found on the website.
Some drugs require prior authorization. Drugs that require prior authorization are noted in the formulary. Your provider must complete a prior authorization form and send it to us so that a decision about coverage can be reached. After the request is reviewed, you and/or your doctor will be informed of our decision. If we approve the drug, you may obtain it from a participating pharmacy. If we do not approve the request, you and/or your doctor will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you our decision.
Step therapy is not used in the HHSC formulary for STAR and CHIP.
The safe use of drugs is encouraged by setting a maximum quantity per month for some drugs. These quantity limits are based on the Food and Drug Administration (FDA) guidelines and the manufacturer’s recommendations. There are circumstances that warrant exceptions to these limits. Your physician can request an exception by contacting us and telling us the reason for the exception. We will inform you about our decision. If we do not approve the request for an exception to the quantity limits, we will tell your physician how to appeal the decision.
You may be asked to take a drug that is chemically different from the drug originally prescribed. This different drug will have the same therapeutic purpose and will be used for the same FDA approved conditions. This is called Therapeutic Interchange. The pharmacist or your prescriber may ask you to take this drug and will explain the reasons why he or she believes this is a better drug choice for you. You do not have to agree. If you do not agree, your original drug prescription will be filled.
Not all drugs are covered. Sendero has criteria for making decisions about covering non-formulary drugs based on medical necessity. Your provider must tell us if a non-formulary drug is needed. After the request is reviewed, your doctor will be informed of our decision. If we approve the drug, you may obtain it from a participating pharmacy. If we do not approve the request, you and/or your doctor will be informed of our decision. You have the right to request an appeal if the request is not approved. We will tell you how to do this when we give you our decision
Do I have to pay out-of-pocket for medical care or medications?
For STAR Medicaid members you do not need to pay for covered services.
For CHIP members you have a copayment which is an amount that a member must pay when using certain benefits within the health care plan. The copayment is due at the time of service. Once the copayment is made, further payment does not need to be made by the member.
Can I seek medical care outside of Sendero’s service area?
If you get sick when you are out of town or traveling call Sendero Customer Service toll-free at 1-855-826-7388.
If you or your child has an emergency while you are out of town or out of state, go to the nearest Emergency Room.
When you or your child will be temporarily away from home, you should contact your PCP ahead of time to schedule appointments or obtain prescriptions to last for the duration of your stay. If you or your child gets sick while he or she is out of town—and it is not an emergency—he or she will still remain under the care of your PCP. With the exception of emergency care, if you or your child sees an out-of-town doctor you may have to pay. If you or your child leaves the Sendero’s service area for an extended period of time, you or your child may be disqualified from STAR or CHIP or have to enroll in a health plan covering another area within the state of Texas. Keep your and your child’s Sendero STAR or CHIP ID Card with you at all times.
Medical services performed out of the country are not covered by STAR or CHIP.
Did you know that Sendero provides language assistance?
If you need to speak to a Customer Service Representatives to a about your benefits, how to get care, or any other questions or concerns. We have bilingual Customer Service Representatives that can help you. Our Customer Service Representatives speak English and Spanish. We also offer over the phone interpreters in other languages. When you call us, you can ask to talk to someone in the language you speak. The services are free. If you need help about your benefits or how to get care or services please call us.
If you need face-to-face interpreter assistance for your doctor’s appointments, Sendero Customer Service toll-free at 1-855-826-7388. For face-to-face services you will have to call at least 48 hours in before your appointment.
What do I do if I get a bill?
You should never get a bill from your PCP or doctor. If you get a bill from a doctor, call at Sendero Customer Service toll-free at 1-855-826-7388, and we will call the provider’s office. We will help explain your benefits.
How do I select a Primary Care Provider (PCP)?
During the enrollment process, you chose a doctor from our list to be your or your child’s PCP. This doctor will make sure that you or your child gets the right care. The PCP will give you and your child regular checkups, write prescriptions for medicines and supplies when you or your child is sick, and tell you if you or your child should see a specialist.
To give you the best care possible, your PCP needs to know your and your child’s medical history. Your medical records are private and confidential. Only you, your PCP, and other approved providers have a right to see them. If you change doctors, be sure to give your new PCP any information needed about your medical history.
How can I find out about the professional qualifications of my provider?
Sendero has a group of different types of health care doctors that can give you care and services. There is information about these doctors is in our directory. We tell you the name, address, phone number and specialty of each doctor in our group of doctors. If you would like more information about our doctors, please call toll-free at 1-855-826-7388. A Customer Service Representatives can tell you where the doctor went to medical school. The Customer Service Representatives can tell you if the doctor did complete their residency and where. The Customer Service Representatives can also let you know the board certification status of any of our PCP’s and specialists.
What if I need to see a special doctor (specialist)?
Your PCP will tell you if you or your child needs to see a specialist. Your PCP will make sure that you or your child gets the special care needed. In general, you cannot go to another doctor or get a special service if your PCP does not agree to make a referral.
NOTE: You are not required to obtain a referral from your PCP to access care from an OB/GYN or behavioral health provider within the Sendero Plan network.
For a list of specialty care providers in the Sendero Plan network, visit our website at www.senderohealth.com. This list is updated every two weeks. You may also call Customer Service for the most current network provider information toll-free at 1-855-826-7388.
How can I access hospital services?
How do I get help if I have behavioral (mental) health, alcohol or drug problems?
How do I get medical care after my Primary Care Provider’s office is closed?
How may I obtain emergency care?
Emergency medical care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions.
Emergency Medical Condition means:
A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:
1• Placing the patient’s health in serious jeopardy
2• Serious impairment of bodily functions
3• Serious dysfunction of any bodily organ or part
4• Serious disfigurement; or
5• in the case of a pregnant woman, serious jeopardy to the health of a woman or her unborn child.
Emergency Behavioral Health Condition means:
• Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson, possessing average knowledge of medicine and health:
1. requires immediate intervention or medical attention without which the Member would present an immediate danger to themselves or others; or
2. which renders the Member incapable of controlling, knowing or understanding the consequences of their actions.
If you believe you have a medical emergency, go to the ER or call 9-1-1:
Emergency Services and Emergency Care means:
Covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an Emergency Medical Condition or Emergency Behavioral Health Condition, including post- stabilization care services.
What should I do if I have a complaint?
We want to help. If you have a complaint, please call us toll-free at 1-855-526-7388 to tell us about your problem. A Sendero Member Services Advocate can help you file a complaint. Just call 1-855-526-7388. Most of the time, we can help you right away or at the most within a few days.
How do I file an appeal?
You may appeal a decision that adversely affects coverage, benefits or your relationship with Sendero Health Plans. If you are not happy with a decision we make, you may file an appeal by phone or mail. You may call us toll-free at 1-855-526-7388. If you need language assistance to file an appeal, let us know and we will provide help for you to file an appeal. You may send a written appeal to:
Sendero Health Plans
2028 E. Ben White Blvd., Suite 400
Austin, TX 78748
Can I ask for a State Fair Hearing? (STAR Members ONLY)
If you, as a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 90 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at 2028 E. Ben White Blvd., Suite 400, Austin, TX 78741 or call 1-855-526-7388.
You have the right to keep getting any service the health plan denied or reduced, at least until the final hearing decision is made if you ask for a fair hearing by the later of: (1) 10 calendar days following the MCO’s mailing of the notice of the action, or (2) the day the health plan’s letter says your service will be reduced or end. If you do not request a fair hearing by this date, the service the health plan denied will be stopped.
If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied.
HHSC will give you a final decision within 90 days from the date you asked for the hearing.
What is an Independent Review Organization (IRO)? (CHIP Members only)
An Independent Review Organization is an organization that the Texas Department of Insurance (TDI) selects to review appeals for health plans. When a member or doctor is not happy with the health plan response, TDI will help make a decision through this organization.
If you are not happy with the results of the Sendero appeal, fill out IRO form that was sent to you with the denial letter. You must return the form to Sendero. Member Services or the Member Advocate can help you fill out this form. We will send your request to TDI right away. To request a review by an Independent Review Organization, call Sendero at 1-855-526-7388. Complete the IRO form obtained from Sendero and mail it to us at:
ATTN: Health Service Department
2028 E. Ben White Blvd., Suite 510
Austin, Texas 78741
How does Sendero evaluate new technology?
We provide for care that is shown to be safe and useful. We review new health care treatments. We review new procedures. The review uses up to date health data. This is called new Technology Assessment. We decide whether to pay for these things. This review means we pay when safety and value is clear. You may ask us to review new technology. The Texas Vendor Drug Program reviews medications.
I do not have a ride to my doctor’s appointment. Can Sendero Health Plans help me with finding a ride?
Yes, Sendero Health Plans can help you find transportation to your doctor’s appointment. The Health and Human Services Commission offers transportation assistance through the Medical Transportation Program (MTP) for STAR members. For eligibility questions contact MTP at1-877-633-8747 (1-877-MED-TRIP). If you are a CHIP member, or have already contacted MTP, calls Sendero’s Member Services at 1-855-526-7388, and ask how Sendero Health Plans can help you with transportation to your doctor’s appointment.
I have recently moved. How do I update my information?
You can update your information two ways. Contact The Health and Human Services Commission at www.YourTexasBenefits.com and click on “View My Case.” From here you can log in and update facts about your profile like your phone number and your address. Also, you can call the Health Human Services Commission at 2-1-1 or 1-877-541-7905.
How do I request a new Sendero Health Plans identification card?
Call Sendero’s Member Services Department at 1-855-526-7388 anytime Monday through Friday 8- 5 pm, and request a new identification card. We will mail you your new identification card the next day.
Can I be a Sendero Health Plans member if my family travels for work in agriculture?
Yes, Sendero Health Plans can also accelerate services if you are planning to, or know when your family will be, traveling outside of the service area. Please call Sendero’s Member Services at 1-855-526-7388 for more information on how we can help you.
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