How to File an Appeal for Benefit Denial or Reduction

FOR STAR and CHIP Members

You may appeal a decision that negatively affects coverage or benefits. 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 1-844-872-0537. 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
Attn: Appeals
2028 E. Ben White Blvd., Suite 400
Austin, TX 78741

What can I do if my doctor asks for a service or medicine for me that is covered but Sendero denies or limits it?
When this occurs, you will be sent a letter explaining our denial. You have the right to appeal this decision. To appeal these medical decisions, call Sendero Member Services at 1-844-872-0537. If you need help filing this appeal, ask Sendero Member Services or a Member Advocate to help you.

How long do I have to file an appeal?
If you want to file an appeal you have 60 days from the date of the denial letter to file an appeal.

How long will it take to process my appeal?
You/your provider may appeal verbally or in writing. If a request for an appeal is received verbally, you/your provider will send a one-page appeal form to put the appeal in writing. We will send you a letter within five (5) days of receiving your appeal, to let you know that we received it. We will complete the appeal review and will send you a written response within thirty (30) days. If we need more time to review the appeal, we will send you a letter telling you why we need more time.

Can I continue receiving services while my appeal is being reviewed?
If you file an appeal within 10 days from the date of the denial letter or before the service end date, whichever is later, you may continue to receive services until a decision is made.

Expedited Appeal

What is an expedited appeal?
An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

How do I ask for an expedited appeal?
Call Sendero Member Services at 1-844-872-0537 to request an expedited appeal. You may request an expedited appeal verbally, or in writing. If you need assistance in filing this appeal, contact Member Services at 1-844-872-0537 and they will contact a Member Advocate to help you with filing an expedited appeal.

What are the time frames for an expedited appeal?
We will review your case and get back to you no later than 3 working days after we receive your request. If the expedited appeal is related to a denial of an urgent, emergent request or an ongoing continued inpatient stay in the hospital, a decision will be made in one business day.

What happens if Sendero denies my request for an expedited appeal?
If we determine that your appeal is not eligible for an expedited appeal, we will handle it as a standard appeal request. You may discuss your request for an expedited appeal with the Medical Director if there are questions. Requests for expedited appeals are very serious. We want to make sure you/your child receive the care that is medically necessary.