Members

Member Services (Medical & Behavioral Health)844-800-4693
Behavioral Health Crisis Line855-765-9696
Envolve Benefit Options (Vision)855-279-9680
Navitus (Pharmacy)866-333-2757
For Hearing Impaired (TTY)711
24 Hour Nurse Advice Line855-880-7019
Liberty Dental Plan (Dental) 866-609-0426
Utilization Management
*You can leave a voicemail if you call after hours and on the weekends. Someone will return your call.
855-895-0475
Monday-Friday
8:00 am to 5:00 pm
Health Equity: (Health Savings Account Vendor)
https://sendero.healthequity.com/He.aspx

Upon clicking this link you will be leaving the Sendero website and going to our partner,
HealthEquity’s site to where you can learn more about Health Savings Accounts and enroll
if you choose. Please note that your personal information will not be collected by or shared with Sendero Health.
866-346-5800
24 hours a day
7 days a week
Click Here to get a complaint form.
Click Here to get an Authorization to Disclose PHI form.
Click Here for a 2019 Medical Claim Form. This form should be used by Members needing to submit a medical claim to IdealCare.
Please be advised that the medical claim form must be received within 95 days from date of service.

Yes, your out of pocket amount due will be the same amount you would pay for a primary care provider (PCP) visit. For example, if your plan offers a $25 copay for a PCP visit, then a behavioral health visit would also have a $25 copay. Your out of pocket amount due is based on the plan you are enrolled in. If you have additional questions, call Customer Service at 1-844-800-4693 Monday – Friday from 8 AM – 5PM.

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.

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.

Prior authorization lets IdealCare know in advance that a specific service is needed for you. Your PCP or in-network treating provider is responsible for obtaining the necessary preauthorization. In the event that your PCP or in-network treating provider fails to obtain preauthorization, services rendered without preauthorization may result in you being balanced billed. However, preauthorization does not guarantee payment of benefits.

The availability of benefits is subject to other requirements of IdealCare, such as medical necessity, limitations and exclusions, payment of premium, and eligibility at the time care and services are provided. IdealCare’s preauthorization program uses written, medically acceptable screening criteria and review procedures that are established and periodically updated with involvement from network providers.

Sendero will notify your PCP or submitting provider of your approval or denial of the prior-authorization request no later than the third day after the date the request was received. If the preauthorization request is for concurrent hospitalization care, Sendero will notify your PCP or submitting provider within 24 hours after the request is received. If the preauthorization is for post-stabilization treatment or life- threatening conditions, Sendero will provide notification to your PCP or submitting provider no later than one hour after the request was received. If Sendero denies the service(s) we will provide written notification within three working days from the telephone or electronic transmission of the adverse determination. If the circumstance involves post-stabilization treatment or life-threatening conditions Sendero will provide a response for the proposed services requested within the time appropriate to the circumstance relating to the delivery of the services and the condition of the member, but in no case to exceed one hour from receipt of the request.

For further information regarding services that require Prior Authorization, Refer to the Evidence of Coverage (EOC) document specific to your plan. The EOC can be found on the IdealCare website by clicking the “Members” Tab, then “Member Benefits”.

Evidenceof Coverage (EOC) is information/documentation provided to members detailing what medical treatments and/or services are paid for IdealCare on behalf of the member. It also defines the Right and Responsibilities of IdealCare and IdealCare’s members.

The EOC can be found on the IdealCare website by clicking the “Members” Tab, then “Member Benefits”. Additionally, a copy of the EOC can be mailed to the member upon request. To Request a copy of the EOC, please call 1-844-800-4693 or write to:

IdealCare Health Plans / IdealCare
2028 E. Ben White Blvd., Suite 400
Austin, TX 78741

If you have any questions regarding the EOC or the information contained within, please contact the customer service line at 1-844-800-4693.

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.

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 1-844-800-4693.

If you need TDD/TTY services, just call 7-1-1.

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.

If you would like to know more about your benefits and services included and/or excluded from your plan please refer to your IdealCare Member handbook. If you need any additional assistance please contact our Customer Service line, toll-free at 1-844-800-4693.

Sendero has a committee of physicians and pharmacists that decide about our medication procedures. They develop our formulary which is a list of the drugs that we prefer our physicians to prescribe. We have a network of pharmacies where you can get your prescription filled. You may obtain the most current information about the drugs we cover by looking at our formulary by clicking here or by calling Customer Services at 1-844-800-4693.

Our team of physicians and pharmacists reviews the available drugs and selects the ones that they believe are the best for our members. This list of our preferred drugs is the formulary. It includes generic and brand name drugs that we believe are the most appropriate, safe and effective drugs for our members. We review the formulary often to be sure it is current. From time to time, we add new drugs and we remove others. We also have different levels of payments for drugs called cost-sharing tiers.

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.

You can review our online formulary by clicking here or by calling Customer Services to check on the coverage for a specific drug. As a member, if the drug you are taking is not listed in our formulary you may ask that we cover the drug. This is called an exception request. Your physician will need to tell us the reasons why he or she believes we should make an exception to our formulary.

Prior Authorization
For some drugs, our approval is required. This is called prior authorization. If your physician decides that you should take a drug in this group, he or she will contact us to receive authorization before giving you a prescription for the drug.

Step Therapy
Some drugs require step therapy. This means that you must try a first step drug before the second step drug will be covered. Usually generic drugs are in the first step.

Quantity Limits
We encourage safe use of drugs 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.

Therapeutic Interchange
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.

For more information about our pharmacy procedures and to see if a drug is included in our formulary, click here, the formulary will tell you about:

  • The drugs included in our formulary.
  • Quantity limits and copayments for drugs.
  • Restrictions that apply to drugs such as prior authorization requirements.
  • How to obtain prior authorization for a drug, if required.
  • How your physician may request an exception to our formulary, including the documentation that we require to review this request.
  • How you or your physician may appeal our decision not to approve the request for an exception.
  • The process for generic substitution of drugs.
  • Step therapy requirements.
  • Therapeutic interchange requirements.

Any other requirements, restrictions, limitations, or incentives that apply to the use of certain drugs.

Any of 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, to 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 five (5) business days

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 in one (1) business day.

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 would like to know if a certain service, procedure, or medication requires a co-pay, coinsurance or deductible; refer to your Summary of Benefits in Coverage (SBC) for a detailed explanation of what requires a co-pay, coinsurance and/or deductible.

If you get sick when you are out of town or traveling call IdealCare Customer Service toll-free at 1-844-800-4693. We will help you get care.

If you need emergency services while traveling, go to a nearby hospital, and then call us 1-844-800-4693. When you or your covered family member 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. Non-emergency services are not covered by IdealCare when you are out of the IdealCare service area. If you receive non-emergency services out of the service area you will be responsible to pay for the balance due to the facility or provider.

If you need to speak to a Customer Service Representative in regards to your benefits, access to care, or any other questions or concerns, we have bilingual Representatives that can help you. Our 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. We have translation services available. The services are free. If you need help understanding your benefits or how to get care or services please call us.

If you need face-to-face interpreter assistance for your provider’s appointments, IdealCare Customer Service toll-free at 1-844-800-4693. For face-to-face interpretation you will have to call at least 48 hours in advance of your appointment.

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 301425
Houston, TX 77230

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.

Members may call in to request a refund of overpaid premiums. The refunds can be processed by two methods, electronically or by a manual check. The type of refund that is issued depends on the method of payment. Payments made with a debit/credit card on our member portal/website, IVR, and/or auto pay, may be reversed to your debit/credit card. Payments made by check/money order to our lockbox or auto pay with a checking or savings account are refunded manually via a live check. Please contact Customer Service at 1-844-800-4693 to request your refund.

An EOB is a statement that we (IdealCare) send to members to explain what medical treatment and/or services we paid for on your behalf, the payment we made, and/or your financial responsibility. An EOB is mailed to members once we have processed a claim. Members receive a copy of the EOB’s via mail and can also be viewed in the Member Portal.

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.

You can access your EOB in Sendero’s Member Portal at https://idealcare.mediview.net/. 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.

Sendero has a network of different types of health care practitioners to provide you with care and service. There is information about these practitioners in our directory. We tell you the name, address, telephone number and specialty of each practitioner in our network. If you would like more information about the professional qualifications of our practitioners, please call Customer Service toll-free at 1-844-800-4693. Customer Services will tell you the medical school attended, the residency completed, and the board certification status of any of our primary care practitioners and specialists.

Once you have chosen an IdealCare Plan, your next choice is to select a provider who will provide the majority of health care services to you and your covered family members. Your primary care provider (PCP) will be the one you call when you need medical advice, when you are sick and when you need preventive care such as immunizations. Each member may select his or her own PCP. You will select a PCP from the IdealCare Plan’s network of family or general providers, internists and pediatricians. The selection of a PCP is crucial for immediate access to acute and preventative care.

For a list of Sendero providers that provide services to IdealCare Plan members, visit our website at www.senderohealth.com/idealcarenetwork. You can also call our Customer Service for assistance toll-free at 1-844-800-4693. Your PCP is your personal provider who will provide and/or coordinate all aspects of your medical care and oversee your course of treatment to ensure that proper care is maintained. Sendero uses standardized processes to evaluate and approve providers for inclusion in the Sendero network. In-network providers are reviewed on a regular basis to ensure they continue to meet Sendero’s standards. Your PCP is your main source of medical care and your link to specialists, hospitals and other providers.

Please assist your PCP by:
Requesting that your prior medical records be transferred to your PCP’s office.
Presenting your IdealCare member ID card whenever you receive medical services.
Paying the provider the applicable deductible(s), copayment(s), and coinsurance at the time of service.
Contacting your PCP as soon as possible after a medical emergency so he or she can arrange for follow-up care.
Obtaining a referral from your PCP before seeking non-emergency specialty medical care, except when accessing care from an obstetrician/gynecologist (OB/GYN) or behavioral health provider.

Your PCP is available, directly or through arrangements for coverage with other providers, 24 hours a day, 7 days a week. If you are admitted to an inpatient facility, a provider other than your PCP may direct and oversee your care. If you have a chronic, disabling or life-threatening condition, you may request to use a specialty care provider as your PCP. For a specialty care provider to be named as your PCP, he or she must meet all Sendero PCP requirements and be willing to accept the responsibility of coordinating all of your health care needs. If you want to request a specialty care provider as your PCP, call Customer Service to make the change request.

The IdealCare Plan covers a full range of specialty services. If your PCP determines that your condition requires treatment by a specialist, he or she will refer you to the appropriate in-network specialist.

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 IdealCare Plan network.

For a list of specialty care providers in the IdealCare Plan network, visit our website at www.senderohealth.com/idealcarenetwork. This list is updated every two weeks. You may also call Customer Service for the most current network provider information toll-free at 1-844-800-4693.

Your PCP or specialist will arrange hospital services for you if you need to be hospitalized.

If you or a family member needs treatment for a mental or emotional disorder or have a problem because of drugs or chemical dependency disorders, call Customer Service toll-free at 1-844-800-4693 or 1-855-765-9696. The IdealCare Plan network includes mental health and substance abuse professionals who can see you and help you get treatment. Some substance abuse or mental health problems, such as severe depression, also may require urgent care. You can access an in-network behavioral health provider directly. You do not need a referral from your PCP.

If you or your family members get sick or have an injury that is severe or painful enough to require assessment and/or treatment at night or on a weekend, you should contact your PCP first, who will advise you based on your symptoms. Your PCP is available, directly or through arrangements for coverage with other providers, 24 hours a day 7 days a week. IdealCare by Sendero Health Plans also has a 24/7 nurse advice line available for you to use. The number is 1-855-880-7019.

Emergency care includes those health care services you receive in a hospital emergency room or comparable facility to evaluate and stabilize certain medical conditions, including behavioral health conditions. These conditions are of a recent onset and severity (such as severe pain) that would lead a person with average knowledge of medicine and health to believe that the person’s condition, sickness or injury is such that failure to get immediate medical care could cause the following:

  • Placing the patient’s health in serious jeopardy
  • Serious impairment of bodily functions
  • Serious dysfunction of any bodily organ or part
  • Serious disfigurement
  • In the case of a pregnant woman, serious jeopardy to the health of the fetus

In addition, here is a limited list of situations that would also be considered medical emergencies. If you believe you have a medical emergency, go to the ER or call 9-1-1:

  • Apparent heart attack
  • Loss of consciousness
  • Chest pain with symptoms of heart attack
  • Stroke
  • Poisoning
  • Severe bleeding
  • Convulsions
  • Fractures
  • Severe abdominal pain of sudden onset
  • Severe injuries or trauma
  • Shock from sudden illness or injury
  • Difficulty in breathing, such as in a severe asthma attack

If you have any questions regarding whether a situation is an emergency, please contact your PCP who will direct you based on your symptoms. You can also call Sendero nurse advice line toll-free at 1-855-880-7019 24/7 to get direction based on your symptoms.

Emergency care services are covered anywhere, in-network and out-of-network, 24-hours a day. If an emergency occurs, you should go to the nearest emergency medical facility. Necessary emergency care services will be provided to you, including treatment and stabilization of a medical condition and any medical screening examination or other evaluation required by state or federal law which is necessary to determine if an emergency exists.

If, after medical screening, emergency treatment is determined not necessary, you must contact your PCP to arrange any non-emergency care needed. If you choose to use the emergency room for non-emergency treatment, you will be responsible for all billed charges. You must contact your PCP before receiving follow-up care, even if you are referred to a specialty care provider from the emergency room or advised to return to the emergency room by the treating provider. You or someone acting on your behalf should contact your PCP within 24-hours or as soon as reasonably possible, so that he or she may arrange for follow-up care.

If you seek non-emergency care at an out-of-network facility you may be balanced billed for additional charges from the hospital.

If you have concerns about or are unhappy about the services or care you have received from IdealCare, an IdealCare provider or any aspect of your health plan benefits, please call us. Call IdealCare’s Customer Service toll-free at 1-844-800-4693. A full investigation of your complaint will be completed and our decisions will be forwarded to you in writing within 30 calendar days from receipt of your verbal or written complaints and/or complaint form. The complaint form can be found on our website at www.senderohealth.com or by calling our Customer Service toll-free at 1-844-800-4693.

IdealCare will not discriminate or take punitive action against a member or a member’s representative for making a complaint, an Appeal, or an Expedited Appeal. IdealCare will not engage in retaliatory action, including refusal to renew or cancellation of coverage, against a member because the member or a person acting on behalf of the member has filed a complaint against IdealCare or appealed a decision of IdealCare.

IdealCare will not engage in retaliatory action, including refusal to renew or termination of a contract, against a provider because the provider has, on behalf of a member, reasonably filed a complaint against IdealCare or appealed a decision of IdealCare.

At any time you may file a complaint with the Texas Department of Insurance (TDI) by writing or calling:

Texas Department of Insurance (TDI)
Consumer Protection, Section MC 111-1A
P.O. Box 149091
Austin, Texas 78714-9091 
1-800-578-4677
E-mail: ConsumerProtection@tdi.texas.gov

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 1-844-
800-4693. 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:

IdealCare by Sendero Health Plans
Attn: Appeals
2028 E. Ben White Blvd.,
Suite 400
Austin, TX 78748

DENIALS OR LIMITATIONS OF PROVIDER’S REQUEST FOR COVERED SERVICES

Sendero may deny health care services that are not considered to be medically necessary. If Sendero denies healthcare services, a letter will be mailed to you with the reason for the denial and an appeal form.

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 Sendero 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.

Within 5 business days of receipt of an oral Complaint, Sendero will send you a letter acknowledging the Complaint. The acknowledgment letter will contain a description of Sendero’s Complaint procedures and time frames as well as a Complaint form for you to fill out and return to Sendero. This form must be returned in order to receive prompt resolution of your complaint. Your Complaint will be investigated and Sendero will respond to you within 30 calendar days from the receipt of the completed Complaint form.

Within 5 business days of receipt of a written Complaint, Sendero will send you a letter acknowledging the Complaint; it will include a description of Sendero’s Complaint procedures and time frames. Your Complaint will be investigated and Sendero will respond to you within 30 calendar days from the receipt of the written Complaint.

Your Complaint response letter will explain the resolution of the Complaint; provide specific medical and contractual reasons for the resolution, specify the specialization of any Provider that consulted on the Complaint, and include a complete description of the process to Appeal, including the deadlines for the Appeals process and deadlines for the final decision of the Appeal.

If you are not satisfied with the resolution to your Complaint, you may initiate a Complaint Appeal. The Complaint Appeal process provides for you to appear in person before a Complaint Appeal panel or to address a written Appeal to the Complaint Appeal panel.

Sendero will send an acknowledgement letter to you within 5 business days of receipt of a written Complaint Appeal request. The acknowledgement letter will detail your rights and outline the Complaint Appeal process. The Complaint Appeal panel will be composed of an equal number of Sendero staff, Providers, and enrollees. Panel members may not have been previously involved in the disputed decision. The Complaint Appeal Panel will deliberate on the Complaint Appeal and advise Sendero on the resolution of the Complaint Appeal.

The Complaint Appeal resolution letter will include a notice of the final decision and include the specific medical determination, clinical basis, and contractual criteria used as the basis of the Complaint Appeal resolution. The Complaint Appeal resolution will be completed within 30 business days from the receipt of the written Complaint Appeal request.

If you are not satisfied with the resolution of your Complaint or Complaint Appeal, you can also complain to the Texas Department of Insurance by calling toll-free to 1-800-252-3439. If you would like to make your request in writing, send it to:

Texas Department of Insurance 
Consumer Protection
Section (MC 111-1A)
P.O. Box 149091
Austin, Texas 78714-9091

Go to the health insurance marketplace where you bought the plan and sign into your account.
If you bought it through HealthCare.gov, log into “My Account,” go to “My Plans and Programs,” and
select “End/Terminate All Coverage.” Or call the Marketplace at 1-800-318-2596 and you can cancel over the phone.

Click here  for more information.

IdealCare by Sendero Health Plans systematically evaluates the inclusion of new technologies and the new applications of existing technologies as covered services in a timely manner. Your insurance benefit provides coverage only for therapies that have been shown in the scientific medical literature to be safe and effective. The IdealCare technology assessment process assures that coverage will be available when evidence of safety and effectiveness exists. A review of current technology as well as care-specific reviews will be conducted by the IdealCare medical technology assessment team using up-to-date information from sources including but not limited to evidence based medical literature, board certified consultants, physician work groups, professional societies, and government agencies. Drugs that are new to the medical community are reviewed and discussed by the IdealCare pharmacy and therapeutics committee.

Case Management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources.

You or your caretaker can contact customer service at 1-844-800-4693 to obtain a referral for Case Management.

To report ,Fraud, Waste or Abuse gather as much information as possible. You must report members or providers directly to Lighthouse Services, and you must include Sendero’s name in your report by using the:
Confidential hotline at 833-290-0001 or
Confidential fax at 215-689-3885 or 
Confidential email at reports@lighthouse-services.com or
Confidential website at www.lighthouse-services.com/senderohealth

If you have questions you can call Customer Service at 1-844-800-4693; or You can report directly to:

Sendero IdealCare
2028 E. Ben White Blvd., Suite 400
Austin, TX 78741

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. Sendero does not hold nor pend claims. Claims pending means that no action, including but not limited to review, has not taken place.

PLANSDOCUMENTSDRUG COSTS
IdealCare Bronze High Deductible
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare Bronze HSA
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare Expanded Bronze
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare Gold
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare Platinum
Off ExchangeEnglish • SpanishLookup Cost
IdealCare Silver
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
73% AVEnglish • SpanishLookup Cost
87% AV English • SpanishLookup Cost
94% AV English • SpanishLookup Cost
IdealCare Silver Direct
Off ExchangeEnglish • SpanishLookup Cost
SelectCare Bronze High Deductible
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
SelectCare Expanded Bronze HSA
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost
SelectCare Expanded Bronze Simple
Off ExchangeEnglish • SpanishLookup Cost
On ExchangeEnglish • SpanishLookup Cost
AI/AN Zero Cost SharingEnglish • SpanishLookup Cost
AI/AN Limited Cost SharingEnglish • SpanishLookup Cost

PLANSDOCUMENTS
IdealCare Gold, Complete, Essential, Silver Direct, Bronze High Deductible, HSA and SelectCareEnglish
PlatinumEnglish

PLANSDOCUMENTS
IdealCare Bronze High Deductible
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
IdealCare Bronze HSA
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
IdealCare Expanded Bronze
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
IdealCare Gold
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
IdealCare Platinum
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
IdealCare Silver
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
IdealCare Silver Direct
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
SelectCare Bronze High Deductible
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
SelectCare Expanded Bronze HSA
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish
SelectCare Expanded Bronze Simple
Medical-Surgical & Behavior Health/Substance Abuse DisorderEnglish
Pharmacy BenefitsEnglish


Member HandbookEnglish • Spanish
Quick Reference GuideEnglish • Spanish

PLANSDOCUMENTSDRUG COSTS
IdealCare Essential (Bronze)
Standard Off ExchangeEnglish • SpanishLookup Cost
Standard On ExchangeEnglish • SpanishLookup Cost
Zero Cost SharingEnglish • SpanishLookup Cost
Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare HSA (Bronze)
Standard Off ExchangeEnglish • SpanishLookup Cost
Standard On ExchangeEnglish • SpanishLookup Cost
Zero Cost SharingEnglish • SpanishLookup Cost
Limited Cost SharingEnglish • SpanishLookup Cost
Bronze High Deductible
Standard Off ExchangeEnglish • SpanishLookup Cost
Standard On ExchangeEnglish • SpanishLookup Cost
Zero Cost SharingEnglish • SpanishLookup Cost
Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare Complete (Silver)
Standard Off ExchangeEnglish • SpanishLookup Cost
Standard On ExchangeEnglish • SpanishLookup Cost
Complete 73% AVEnglish • SpanishLookup Cost
Complete 87% AVEnglish • SpanishLookup Cost
Complete 94% AVEnglish • SpanishLookup Cost
Zero Cost SharingEnglish • SpanishLookup Cost
Limited Cost SharingEnglish • SpanishLookup Cost
IdealCare Silver Direct
Standard Off ExchangeEnglish • SpanishLookup Cost
IdealCare Gold
Standard Off ExchangeEnglish • SpanishLookup Drug Cost
Standard On ExchangeEnglish • SpanishLookup Drug Cost
Zero Cost SharingEnglish • SpanishLookup Drug Cost
Limited Cost SharingEnglish • SpanishLookup Drug Cost
IdealCare Platinum
Standard Off ExchangeEnglish • SpanishLookup Drug Cost

PLANSDOCUMENTS
Gold, Complete, Essential, Silver Direct, Bronze High Deductible and HSAEnglish
PlatinumEnglish

PLANSDOCUMENTS
IdealCare Essential (Bronze)
SOC Medical Surgical & Behavior Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
IdealCare HSA (Bronze)
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
Bronze High Deductible
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
IdealCare Complete (Silver)
Complete Standard SOC Medical Surgical & Behavior Health ServicesEnglish
Complete Standard SOC Pharmacy BenefitsEnglish
Complete Silver 73 AV SOC Medical Surgical & Behavior Health ServicesEnglish
Complete Silver 73 AV SOC Pharmacy BenefitsEnglish
Complete Silver 87 AV SOC Medical Surgical & Behavior Health ServicesEnglish
Complete Silver 87 AV SOC Pharmacy BenefitsEnglish
Complete Silver 94 AV SOC Medical Surgical & Behavior Health ServicesEnglish
Complete Silver 94 AV SOC Pharmacy BenefitsEnglish
IdealCare Silver Direct
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
IdealCare Gold
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
IdealCare Platinum
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish


Member HandbookEnglish • Spanish
Quick Reference GuideEnglish • Spanish

PLANSDOCUMENTS
Bronze (IdealCare Essential)
Standard Off ExchangeEnglish • Spanish
Standard On ExchangeEnglish • Spanish
Zero Cost SharingEnglish • Spanish
Limited Cost SharingEnglish • Spanish
Bronze HSA (IdealCare Essential HSA)
Standard Off ExchangeEnglish • Spanish
Standard On ExchangeEnglish • Spanish
Zero Cost SharingEnglish • Spanish
Limited Cost SharingEnglish • Spanish
Silver (IdealCare Complete)
Standard Off Exchange 1English • Spanish
Standard Off Exchange 2English • Spanish
Standard On ExchangeEnglish • Spanish
Complete 73% AVEnglish • Spanish
Complete 87% AVEnglish • Spanish
Complete 94% AVEnglish • Spanish
Zero Cost SharingEnglish • Spanish
Limited Cost SharingEnglish • Spanish
Gold (IdealCare Total)
Standard Off ExchangeEnglish • Spanish
Standard On ExchangeEnglish • Spanish
Zero Cost SharingEnglish • Spanish
Limited Cost SharingEnglish • Spanish
Platinum (IdealCare Premier)
Standard Off ExchangeEnglish • Spanish

PLANSDOCUMENTS
Bronze, Silver and Gold (IdealCare Essential, Complete and Total)English
Platinum (IdealCare Premier)English

PLANSDOCUMENTS
Bronze (IdealCare Essential)
SOC Medical Surgical & Behavior Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
Silver (IdealCare Complete)
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
Gold (IdealCare Total)
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish
Platinum (IdealCare Premier)
SOC Medical Surgical & Behavioral Health ServicesEnglish
SOC Pharmacy BenefitsEnglish


Member HandbookEnglish • Spanish
Quick Reference GuideEnglish • Spanish

Sendero offers access to Seton, St David’s, ARC and many more local physicians to make sure you get the care you need. Additionally, we are happy to announce free telemedicine for all Marketplace members!

IdealCare is here to provide coverage for the most important person . . . you!

We offer lower costs and increased coverage to keep you healthy with insurance coverage that fits your needs. You may qualify for tax credits to lower your premium or cost-sharing reductions to decrease your out-of-pocket cost for IdealCare.

Coverage includes doctor visits, hospitalization, maternity care, emergency room care, and prescriptions.

You qualify for IdealCare if you have no health insurance and are between the ages of 18-64 years old. You also must be a U.S. citizen or resident and live in Travis, Hays, Bastrop, Burnet, Lee Caldwell, Fayette or Williamson counties.

Sendero Health Plans is offering IdealCare through the Health Insurance Marketplace. The marketplace promises fair treatment for patients.

Sendero Health Plans can help you complete the IdealCare application. We will tell you the cost and explain the coverage for the plan you choose in easy-to-understand language. There are no hidden fees and no fine print.

Simple. Local. IdealCare.

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.

Welcome to the Sendero Health Plan wellness page. We strive to provide value added services and programs to support the health of our members and our community. This page will serve as a resource for members to use various services, programs and tools to better manage member health and health information. Sendero endorses and recommends referring IdealCare members to the following resources: 

An online personal health record helps you to keep track of your health data through a FREE PHR from WebMD, one of American’s most trusted sites for health care content. You can keep track of immunizations, lab results, food intake and much more. Click Here to create your personal health record.

WebMD provides valuable health information, tools for managing your health, and support to those who seek information. You can trust that content is timely and credible. Click Here to read more about WebMD.

The following tool will help you assess your current health status and risk factors that affect your health. The tool also has questions on healthy behaviors (e.g. smoking, alcohol use, diet and exercise, etc.). This is an important tool for you to complete because it helps you understand your health better. The tool can take between 20 – 30 minutes to complete. At the end of the assessment, the tool will provide you with a summary of your responses and some tips on how you can stay or become more healthy. You will also be able to download this information. Click Here for survey.

The following tool will help you assess your use of alcohol. This tool has 10 questions and will take approximately 3 minutes to finish. At the end of the assessment, the tool will provide you with a score regarding your drinking habits and what this means for you. You will also be able to download information on alcohol use and its impact on your health. Click Here for survey.

The following tool will help you assess your Body Mass Index. The BMI is a measure of body fat. You only need to enter your height and weight. At the end of the assessment, the tool will provide you with your body mass index and what your index means. You will also be able to download information on how to maintain or improve your health. Click Here for survey.

The following tool will help you determine if you have any depressive symptoms. This tool has 22 questions and will take approximately 3 – 5 minutes to finish. These questions are related to your mood and lifestyle (for example, eating, sleeping, social engagement, etc.). At the end of the assessment, the tool will provide you with a score regarding your depressive symptoms and what this means for you. You will also be able to download information on depression and its impact on your health. Click Here for survey.

The following tool will help you assess your knowledge of how many calories there are in the different types of food items we eat on a daily basis. This tool has 10 questions and will take approximately 3 minutes to finish. At the end of the assessment, the tool will provide you more information on the number of calories present in the different foods you eat. You will also be able to download information how to improve your eating habits at the end of the assessment. Click Here for survey.

The following tool will help you assess the level of stress in your life in the last 1 month. This tool has 10 questions and will take approximately 3 minutes to finish. At the end of the assessment, the tool will provide you with a score related to your stress level and what this means for you. You will also be able to download information how to better deal with stress and improve your health. Click Here for survey.

Nicotine is the chemical in cigarettes that makes you want to keep smoking. Finding out how much you depend on nicotine will help you as you choose quit smoking strategies for your quit plan. Remember—no matter what your score, you’ll have to work hard to quit for good. Answer the following questions. The results will explain how much you depend on nicotine and provide ideas on how to reduce your cravings. Click Here for survey.

The following tool asks you questions about your physical activity. The questions also focus on possible barriers that prevent you from exercising. This tool has 21 questions and will take approximately 3-5 minutes to finish. At the end of the assessment, the tool will provide a score related to your physical activity and the barriers that affect your likelihood of exercising. You will also be able to download information on how to increase the amount of exercise you get and how this can improve your health. Click Here for survey.

Smoking Cessation – http://smokefree.gov/
This web site provides information and tools to help people of all ages quit smoking, manage withdrawal, eat healthier, and manage your mood. In English and Spanish.

Stop Smoking – http://www.lung.org/stop-smoking/
This web site provides information about smoking and how to quit.

Stay away from Tobacco – http://www.cancer.org/healthy/stayawayfromtobacco/quit-for-life
This web site has a smoking quiz, guide to stop smoking, guide to stop using smokeless tobacco, help with cravings, secondhand smoke information, and tobacco and cancer fact sheets.

Click Here for additional information on Sendero’s Smoking Cessation Program “Up In Smoke”.

NOTICEDOCUMENTS
2019
Fall Movie NightsEnglish • Spanish
Q4 Member NewsletterEnglish • Spanish
Back to School Event 2019English • Spanish
Explanations of Benefits (EOB) UpdateEnglish • Spanish
Q3 Member NewsletterEnglish • Spanish
Community Event: 06/15/2019 – 06/16/2019 Univision CopaEnglish • Spanish
Q2 Member NewsletterEnglish • Spanish
Q1 Member NewsletterEnglish • Spanish
2018
Winter NewsletterEnglish • Spanish
Behavioral Health
Beacon Health Options Termination Notice (01/08/19)English • Spanish