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1 2028 E. Ben White Blvd., Suite 400 Austin, TX NM-NEWS49 Get the information you need now! New Features On Our Website! Check out enhancements to our website such as: Provider Search function Improved access to Provider educational information News updates Frequently Asked Questions Have suggestions on how we can make it easier to conduct business with us? us at We want to hear from you!

2 Spring 2014 Provider Update Sendero health Plans Transitioning to New Behavioral health vendor In continuing efforts to deliver the best member care and to ensure sound business decisions regarding the growing needs of behavioral health management, Sendero will be partnering with Beacon Health Strategies, LLC to provide behavioral health benefit management services to Medicaid (STAR) and CHIP members effective January 1, On January 1, 2014, Beacon will be responsible for the following functions: Care and utilization management Inpatient and outpatient authorization requirements Member/Patient Services Claim Adjudication/Payment Services As of June 1, 2014, Beacon will assume the additional responsibilities of Network Operations, inclusive of Provider Contracting, Credentialing and Provider Relations. All claims for Behavioral Health services should be directed to Beacon effective January 1, Effective January 1, 2014, all Behavioral Health claims should be sent to the following address: Beacon Health Strategies Claim Departments 500 Unicorn Park Drive, Suite 401 Woburn, MA If you have any questions regarding the transfer of operational services, including clinical and claims processes, please contact Sendero Network Management Department at Behavioral Health Contact Numbers: CHIP: STAR: ChildrEN Of Traveling farmworkers In Texas, children of traveling farmworkers face higher proportions of dental, nutritional, and chronic health problems. Sendero Health Plans will assist children of traveling farmworkers in receiving accelerated services before they leave the area. Please call Sendero Health Plans Member Services at if you identify a Member that is a child of a traveling farmworker. We offer help with: Getting family checkups with a provider before migrating to another area Transportation to a provider office for a THSteps medical checkup Finding a doctor or dentist

3 Understanding waste, Abuse and Fraud The Texas Health and Human Services Commission s Office of the Inspector General (OIG) was created by the Texas Legislature in 2003 to prevent, detect, and pursue waste, abuse and fraud. Since that time, OIG has identified over $7 billion dollars in erroneous, wasteful or fraudulent payments for cost avoidance or recovery. But how exactly does OIG define waste, fraud and abuse and what are some examples of things to avoid? Abuse Practices that are inconsistent with sound fiscal, business, or medical practices and that result in unnecessary program cost. For example, abuse can include reimbursement for services that are not medically necessary, or that do not meet professionally recognized standards. These actions are indicators of abuse: Misuse of prescription medications Misuse of medical services Over-treatment of a client Inappropriate referral patterns Performing unnecessary services Underutilization potentially leading to inappropriate or ineffective care In managed care: Delaying or denying care or services to enrollees Creating difficult or unreasonable prior authorization requirements to avoid paying for certain procedures Delaying first contact with clients, or delaying the assignment of a primary care physician Failure to serve individuals with cultural or language barriers Creating cumbersome appeals processes Maintaining an ineffective grievance process Delays in providing referrals to specialists Providing incentives to illegally limit services Waste Practices that a reasonably prudent person would deem careless or that would allow inefficient use of resources, items or services. Example: Public money spent on unnecessary program administration is considered wasteful. These actions are indicators of waste: Billing for unnecessary services Allowing more DME supplies per month than needed by the client Upcoding for evaluation and management services to obtain higher reimbursement Fraud Any act that constitutes fraud under applicable federal or state law, including any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person. Fraud may include any acts prohibited by the Texas Human Resources Code, Chapter 36, or Texas Penal Code, Chapter 35A. Under the Texas Medicaid Fraud Prevention Act, it includes knowing, willful and reckless acts. These actions are potential indicators of provider fraud: Inflating bills Double-billing Up-coding / unbundling Billing for services never rendered Inappropriate cost shifting Billing for service previously provided Falsifying medical records, provider enrollment documents, Title XIX forms Stark Law and Anti-Kickback Statute violations Medicaid card sharing schemes Billing for services performed by others If you have any information about fraud and abuse, please contact Sendero Health Plans. You can report fraud and abuse without giving your name by calling our Confidential Hotline at Or you may also call the OIG Hotline at or visit https://oig.hhsc.state.tx.us/ to complete the Online Complaint Form. Source: Texas Health and Human Services Commission

4 Check out the value-added BENEfits that Sendero MEMBErs receive! Children & Teens: One year membership to the Boys and Girls Clubs in Bastrop, Hays, Travis or Williamson counties One Youth Sports Session at the YMCA of Austin each year for members ages 5-14 in Travis and Williamson counties Swim session at the YMCA of Austin for members ages 6 months to 18 years old $50 GameStop gift card after completing a timely Well-Child/Adolescent Well-Care visit within 90 days of member enrollment date Pair of movie passes after completing a timely Well-Child/Adolescent Well-Care visit within 60 days of member birthday One sports/school physical each year for members 18 years old and younger Pregnant Moms & Babies: Home baby monitor after completing initial OB appointment for pregnant women within 42 days of enrollment date $250 of basic dental services for pregnant women Pre-programmed cell phones for women who have a high-risk pregnancy One home visit for new moms Newborn Care Kit after completing one Well-Child Visit for newborns within 14 days from birth First aid kit and infant thermometer after completing timely post-partum visit Toddler Home Safety Kit after completing required Well-Child visits for certain members Rides to birthing classes for pregnant members All Members: 24-hour Nurse Advice line Help finding a ride to doctor appointments $10 Academy Sports + Outdoors gift card for completing a new member Health Assessment form within 45 days of enrollment date Up to $50 towards smoking cessation products for CHIP members $100 toward eye glasses for members 2 years of age and older *CHIP once per year and STAR once every two years ATTENTION PROVIDERS: Sendero Medical Management Fax Number Change Fax number has changed to Please make a note of the new fax number for Sendero Medical Management. New fax number:

5 icd-10 Update The U.S. Department of Health and Human Services (HHS) has mandated the replacement of the International Classification of Diseases, 9th Revision (ICD-9) diagnostic and procedure code sets with the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and the ICD-10 Procedure Coding System (ICD-10-PCS). Sendero intends to fully comply with the legal requirements of the ICD-10 mandate and we strongly encourage our providers to do the same. Beginning October 1, 2014, Sendero will process claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient) prior to October 1, We will continue to process ICD-9 coded claims for the entire contractual run-out period or according to timely filing requirements. The ICD-10 code set must be used on all outpatient claims with dates of service on or after October 1, 2014, and on all inpatient claims with a date of discharge on or after October 1, The media used to submit the claim (paper or electronic) will not impact the code set required on the claim. As per the Federal mandate, Sendero will only process claims that contain ICD-10 diagnosis and inpatient procedure codes for service dates/discharge dates on and after October 1, Sendero will monitor CMS s position and adjust our approach if necessary. Changes in Provider information All Sendero network providers are required to notify Sendero in writing of any changes in office address or in relevant contact information at least 30 days prior to the change. This includes notifying Sendero when a provider is leaving a group practice or joining another group practice. All changes must be submitted in writing using the Provider Information Form (PIF) found in Appendix A of your Sendero Provider Manual or by ing us at with the updated information. Effective April 1, 2014: New CMS-1500 Form A new CMS-1500 form was implemented effective January 1, 2014 preparing the way for the transition to ICD-10. Sendero has been in a 3 month grace period during which providers have been allowed to use either the old or the new form. Effective April 1, 2014 providers are required to use the new CMS-1500 form if they are submitting claims on paper. Please note that on and after April 1, 2014, Sendero will be required to return claims that are submitted on the wrong form. After Hours Coverage Sendero Health Plans requires that Primary Care Providers (PCPs) must ensure that access to medical care is accessible to Sendero Members 24 hours a day, seven days a week. Sendero guidelines require PCPs to have an answering service that is able to reach the physician or an answering machine message indicating how to reach the physician or other provider(s) accepting calls. All calls to providers must be returned within 30 minutes. The following are unacceptable telephone arrangements for your office after normal business hours: The office telephone is only answered during office hours. The office telephone is answered after hours by a recording that tells patients to leave a message.

6 ParENtal Accompaniment Rule EnforcEMENt Beginning April 15, 2014 Starting April 15, 2014, HHSC will begin enforcing a rule that requires a parent, guardian, or another adult approved by the parent to stay with a child age 14 or younger when the child goes for a Medicaid service. This includes the time the child is traveling to and from the visit if the ride is set up through HHSC s Medical Transportation Program. Parents and guardians who are not able to go with their child to these appointments must identify an adult to go with the child and make sure the paperwork that authorizes that adult is on file with HHSC. Specifically: If a parent or guardian can t go with their child to a doctor, dentist, or other Medicaidrelated visit, that parent must tell HHSC the name of the adult who will go with the child. The authorized adult cannot be the doctor or specialist providing the child s Medicaid services, an employee of that Medicaid provider, or someone paid by that provider. The parent also can choose a backup adult in case the first adult chosen cannot go with the child. The parent must fill out a Parent Authorization Form and send it in so HHSC will know which adult is authorized to go with the child. The adult who goes with the child must be present when the child is picked up, show a photo ID to the driver, and sign the driver log. Parents can get a Parent Authorization Form and get answers to questions by calling HHSC s Medical Transportation Program toll-free: Houston / Beaumont area: Dallas / Fort Worth area: All other areas: (1-877-MED TRIP) Source: Texas Health and Human Services Commission PRIMARY CARE RATE INCREASE update The Affordable Care Act (ACA) provides a temporary rate increase for certain primary care providers and services from January 1, 2013 through December 31, To be eligible to receive supplemental payments, providers must complete and submit an attestation form to TMHP. The form is available on the TMHP website at ACA%20Primary%20Care%20Attestation.pdf. Only providers who meet the specialty and board certification or Medicaid billing volume requirements described on the attestation form are eligible for supplemental payments. Providers who complete the form before April 1, 2014 will qualify to get the rate increase payments for services provided since January 1, Those who complete the form after April 1st will get the rate increase payments only for services provided from the date they completed the form. Eligible providers did receive a reimbursement check passed through Sendero Health Plans which was mailed to the attested address. The first payment is for applicable services provided during the first quarter of 2013 and does not include claims that required adjustments. Sendero did not supply calculation data for the first supplemental payment. Retrospectively, Sendero did mail data regarding the associated supplemental payments to aid in payment posting efforts. Moving forward, Sendero will send corresponding claims data with all supplemental payments. Providers can call the TMHP contact center at for questions related to the ACA PCP rate increase. NM-NEWS49 3/2014

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