Prospective Member Communication
Sendero Health Plans has procedures to guide us in making decisions about using your health care benefits. Our goal is to assure that you use your benefits appropriately in an efficient, quality-driven, cost-effective manner.
For some services such as physical therapy, speech therapy, chiropractic care there may be a defined number of visits per year.
Sendero Health Plans has a Network of participating providers. These providers have contracted with us to treat our members. There are many different types of providers in our Network so that all of your health care needs can be met.
If you seek care and services from a provider who is not in Sendero’s Network, without a referral, you will have to pay for those services.
When Sendero helps to arrange non-emergency services for you outside its service area, we will cover the cost. If you obtain out of service care without our help, you will be responsible to pay for those services.
Sendero does not cover care provided when you are out of the country. You will have to pay for all medical services received in a foreign country.
For more information about our utilization procedures, our provider and practitioner network and potential network, service or benefit restrictions, please contact Customer Services at 1-800-791-6511 or 512-593-6227. We will provide our Provider Directory and schedule of benefits, upon request.
Practitioner and Provider Availability
Sendero Health Plans has a Provider Network for Austin and the surrounding areas. There are many different types of facilities and practitioners. We have a Provider Directory to help you select the physician and hospital that meets your needs. We encourage you to select a primary care practitioner (PCP) to oversee and coordinate your care. We have standards for how many practitioners and facilities we need in our Network and standards for what types of practitioners and facilities. We measure at least annually to be sure we meet those standards. You do not need prior authorization to see a primary care practitioner.
Approval for Services
Many services require approval before you can receive the service. This is called pre-service approval. For example inpatient hospital care that is not an emergency requires approval. This means your physician must call us for approval prior to admitting you to the hospital. It is the physician’s responsibility to obtain approval for services when indicated. If approval is not granted, the process to appeal the decision will be explained.
Some services do not require pre-service approval, Click here to see the list.
If you are hospitalized or if you are receiving care over a long period of time, we will review your condition on a regular basis to determine if your care continues to be covered. To be covered your care must continually meet criteria for the level of care you are receiving. This process of ongoing review is called concurrent review. Our staff will discuss the status of your condition with your provider. If we do not approve your provider’s request for continued care in the hospital or other setting, the process to appeal the decision will be explained to your provider and to you.
What are my prescription drug benefits?
You can get your prescriptions through your STAR Medicaid and CHIP/CHIP Perinate coverage if you go to a pharmacy that takes Sendero Health Plans Members. There are some medications that may not be covered through STAR Medicaid and CHIP/CHIP Perinate.
The medication may be ordered by your doctor or another doctor treating you or your child. Medication can also be ordered or given while you are in an emergency room or hospital.
You can find the formulary listed on the Texas Medicaid Formulary.
Who can help me get my prescription drugs?
Members can call Member Services toll-free at 1-844-872-0537 Monday to Friday, 8:00 a.m. - 5:00 p.m. if:
If you have a hearing problem, call our TTY line at 7-1-1.