CurrentSendero Health PlansPolicy 696

Physician and Provider Preauthorization Exemptions

Customize your policy alerts

Sign up for senderohealthplans Policy 696 alerts

Get alerted when Policy 696 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs how Sendero identifies, grants, reviews, rescinds, and independently reviews preauthorization exemptions for physicians and providers treating members in IdealCare products, including notification, documentation, claim, and appeal requirements.

Policy Summary

PayerSendero Health Plans

PolicyPhysician and Provider Preauthorization Exemptions

Policy CodePolicy 696

Change TypeNew policy

Effective DateOctober 1, 2022

Last ReviewJul 1, 2022

Next Review DateN/A

Key ActionProviders must submit requested retrospective review medical records within 30 calendar days to avoid possible exemption rescission.

SourceLink

POLICY UPDATE CHANGES

This document establishes a new policy for physician and provider preauthorization exemptions.

90%Approval rate required for an initial exemption

6 monthsMinimum exemption duration unless rescinded

5-20 claimsRetrospective review sample per exempt service and provider

30 daysDeadline to submit requested review records

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentSendero Health PlansPolicy 696

Physician and Provider Preauthorization Exemptions

Customize your policy alerts

Sign up for senderohealthplans Policy 696 alerts

Get alerted when Policy 696 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerSendero Health Plans

PolicyPhysician and Provider Preauthorization Exemptions

Policy CodePolicy 696

Change TypeNew policy

Effective DateOctober 1, 2022

Last ReviewJul 1, 2022

Next Review DateN/A

Key ActionProviders must submit requested retrospective review medical records within 30 calendar days to avoid possible exemption rescission.

SourceLink

POLICY UPDATE CHANGES

This document establishes a new policy for physician and provider preauthorization exemptions.

90%Approval rate required for an initial exemption

6 monthsMinimum exemption duration unless rescinded

5-20 claimsRetrospective review sample per exempt service and provider

30 daysDeadline to submit requested review records

30 daysExemption continuation after rescission notice

5 daysNotification period after IRO determination

Exemption Eligibility and Rescission Criteria

Initial Approval and Continued Exemption Criteria

A provider may receive and retain a preauthorization exemption for a specific healthcare service when all applicable initial-review and continuation criteria are met.

Initial exemption determination

Sendero conducts initial exemption determinations once every six months, identifying providers for review based on the volume of medical-necessity preauthorization determinations by healthcare service code listed on the preauthorization code lookup list and individual NPI.
The provider submitted and had determined at least five eligible preauthorization requests during the evaluation period.>= 5 eligible requests
The provider achieved a preauthorization approval rate of at least 90% for the eligible requests during the evaluation period.>= 90% approval rate
Sendero sends an Initial Notice of Exemption for Certain Healthcare Services identifying the exempt service or services.

Effect and duration of an approved exemption

After receiving the Initial Notice of Exemption, the provider is not required to obtain preauthorization from Sendero for the service or services listed on the notice.
The exemption remains in place for a minimum of six months, unless and until Sendero issues an exemption rescission notice.>= 6 months
Sendero conducts retrospective medical-necessity reviews of exempt services no more than twice a year.

Continuation of exemption

For each provider and exempt service, Sendero selects a random sample of claims for retrospective review.5–20 claims per exempt service
Sendero requests the medical records associated with each sampled claim using the provider’s preferred contact information for exemption correspondence.
Sendero reviews the records using the medical-necessity criteria that would have applied during preauthorization review for the service in the relevant evaluation period.
If at least 90% of the reviewed claims for a particular service met the applicable medical-necessity criteria, the exemption remains in place for that service.>= 90% of reviewed claims

Rescission and Claim-Risk Criteria

An exemption may be rescinded, or the preauthorization waiver may be unavailable for a claim, when any of the following conditions apply.

Retrospective review and records requirements

Sendero conducts retrospective medical-necessity reviews of exempt services no more than twice a year and promptly performs the review after receiving the requested medical records.
The provider responds to a Retrospective Review Records Request by faxing or delivering all necessary records within 30 calendar days of the request.Within 30 calendar days
Providers should monitor their preferred email address, fax number, or mailing address for exemption correspondence. Failure to provide records within the stated timeframe may lead to rescission.

ONE of the following rescission conditions

The semi-annual retrospective medical-necessity review finds that less than 90% of the claims for a particular exempt service met the applicable medical-necessity criteria.

Service Codes and Operational Thresholds

Service-code eligibilitymixed

Preauthorization code lookup list

Service codes used to identify eligible preauthorization determinations for exemption review

Initial Review Eligibility

Minimum volumeAt least 5 eligible preauthorization requests must be submitted and determined during the evaluation period.

Review frequencySendero conducts initial exemption determinations once every six months.

Review basisEligibility is evaluated by health care service code and individual NPI.

Approval and Continuation Threshold

Initial exemption approvalA provider must meet a 90% preauthorization approval rate to receive an exemption notice.

Continued exemptionAt least 90% of claims for the particular service must meet the applicable medical necessity criteria during retrospective review.

Provider Responsibilities and Exemption Workflow

Documentation Required

Maintain Exemption Correspondence Information

Providers must supply Sendero with their preferred method for receiving exemption correspondence for each NPI. Providers must circulate every exemption approval, denial, or rescission notice received to each affiliated office and group where Sendero Members are treated.

Preferred correspondence methods are fax, email, or mail.
Instructions for notifying Sendero are included on exemption correspondence and published on Sendero's provider website authorization pages.

Note

Initial Exemption Review Eligibility

Sendero conducts initial exemption determinations once every six months. A provider is eligible for initial review when Sendero identifies the provider based on medical-necessity preauthorization determination volume by service code and individual NPI and at least five eligible preauthorization requests were submitted by and determined during the evaluation period.

The review uses service codes listed on Sendero's preauthorization code lookup list.

Key Policy Definition

Preauthorization Exemption

Who qualifiesA physician or provider qualifies when Sendero has notified them of a preauthorization exemption.

What is exemptThe exemption applies to a specific health care service, such as a service code or drug.

EffectThe physician or provider is not required to obtain preauthorization for that service for members in the health benefit plan specified on the exemption notice.

Policy Summary

PayerSendero Health Plans

PolicyPhysician and Provider Preauthorization Exemptions

Policy CodePolicy 696

Change TypeNew policy

Effective DateOctober 1, 2022

Last ReviewJul 1, 2022

Next Review DateN/A

Key ActionProviders must submit requested retrospective review medical records within 30 calendar days to avoid possible exemption rescission.

SourceLink

On This Page

< 90% of reviewed claims

The provider fails to supply the requested records for the retrospective medical-necessity review within the requested 30 calendar days.

Rescission notice and effective period

Sendero sends the provider a Notice of Rescission of Preauthorization Exemption through each provider’s preferred exemption communication method.
The exemption remains in place for 30 days after Sendero notifies the provider of the rescission.30 days

Claim requirements when relying on the waiver

Claims from treating physicians or providers must include the name and NPI of the ordering physician or provider in fields 17 and 17B of the CMS-1500, fields 76–79 of the UB-04, another appropriate UB-04 field, or the corresponding fields on an electronic claim using the ASC X12N 837 format.
These requirements are based on 28 TAC §19.1731 and the clean-claim requirements in TAC 21.2803.
If the ordering physician or provider’s name and NPI are not included on the claim, Sendero cannot waive the preauthorization requirement; the claim will deny unless a medical-necessity approval preauthorization is in place.
The exemption applies only when the required ordering-provider information is present on the claim.
A post-acute-care preauthorization request includes the name and NPI of the treating provider from the referring facility who determined that post-acute care is needed and is requesting the preauthorization.

Below thresholdAn initial exemption may be denied, or an existing exemption rescinded, when the applicable rate is below 90%.

Exemption Duration

Minimum durationAn exemption remains in place for a minimum of six months.

ExceptionThe exemption may end earlier if Sendero issues an exemption rescission notice.

Review cycleSendero conducts retrospective medical necessity reviews twice a year for exempt services.

Retrospective Review Sample

Minimum sampleSendero selects not fewer than 5 claims.

Maximum sampleSendero selects not more than 20 claims.

Sampling scopeThe random sample applies to each particular exempt service for each provider.

Records Submission

Submission deadlineProviders have 30 calendar days to fax or deliver the necessary medical records to Sendero.

Records requestedThe records must be associated with each claim selected for retrospective review.

Failure to submitFailure to provide records within the stated timeframe may lead to rescission of the exemption.

Post-Rescission Continuation

Continuation periodThe exemption remains in place for 30 days after Sendero notifies the provider of rescission.

Notification methodSendero sends a Notice of Rescission of Preauthorization Exemption through the provider's preferred exemption communication method.

TriggerThe continuation period begins when Sendero notifies the provider about the rescission.

IRO Determination

Determination deadlineThe IRO must make a determination within 30 days after the physician or provider files the appeal.

Appeal basisA provider may appeal a rescission decision by completing the Request for a Review by an IRO form contained within the Rescission Notice.

Review assignmentFor appeals forwarded to TDI, TDI assigns the case to an IRO.

IRO Outcome Notification

Notification deadlineSendero will notify the provider of the IRO appeal outcome within 5 days.

Starting pointThe 5-day period begins when Sendero receives the determination from TDI.

Outcome communicatedThe notification concerns the outcome of the IRO appeal.

The eligibility threshold is at least 5 eligible preauthorization requests during the evaluation period.

Prior Authorization

Initial Exemption Approval

Sendero will send an Initial Notice of Exemption for Certain Healthcare Services when an eligible provider has a 90% or higher preauthorization approval rate. After receiving the notice, the provider is not required to obtain Sendero preauthorization for the services listed in the notice.

The exemption remains in place for a minimum of 6 months unless and until Sendero issues a rescission notice.
Sendero conducts retrospective medical-necessity reviews of exempt services no more than twice a year.

Unsupported block type: denial_risk

Documentation Required

Ongoing Retrospective Review

No more than twice a year, Sendero conducts retrospective medical-necessity reviews of exempt services. For each provider and particular exempt service, Sendero selects a random sample of no fewer than 5 and no more than 20 claims and reviews the associated records using the medical-necessity criteria that would have applied during preauthorization review for the relevant evaluation period.

Sendero performs the review promptly upon receipt of the medical records.
The review determines whether the exemption is subject to rescission.

Documentation Required

Respond to Records Requests

Providers must submit the medical records associated with each claim selected for retrospective review within 30 calendar days. Sendero requests the records using the provider's preferred exemption-correspondence method, and the provider should monitor its designated email, fax number, or mailing address for a notice titled Retrospective Review Records Request.

Records may be faxed or delivered to Sendero.
Failure to provide the records within 30 calendar days may lead to rescission of the exemption.

Prior Authorization

Continuation of Exemption

An exemption remains in place for a particular service when Sendero's retrospective medical-necessity review determines that at least 90% of the reviewed claims met the applicable medical-necessity criteria.

Continuation applies to the service identified in the initial exemption notice.

Unsupported block type: denial_risk

Documentation Required

Appeal a Rescission

A provider may appeal a rescission by completing the Request for a Review by an IRO form included with the Rescission Notice and faxing it to Sendero at (512) 901-9724 to request expedited IRO review. If the rescission was based on failure to submit medical records, the provider must include those records with the appeal.

The provider must take the required action by submitting the completed form and, when applicable, the missing medical records.

Note

Independent Review Process

Upon receiving an IRO appeal request, Sendero sends the appeal records to the Texas Department of Insurance (TDI). TDI assigns forwarded cases to an independent review organization (IRO), which must decide the appeal within 30 days after the physician or provider files it; Sendero notifies the provider of the outcome within 5 days after receiving TDI's determination.

For rescissions caused by lack of records, Sendero may instead choose to review records submitted with the appeal internally.
The internal-review exception applies to appeals based on failure to provide records.

Prior Authorization

Requests for Exempt Services

Sendero will not process a preauthorization request submitted by a requesting or ordering provider when that provider is exempt for the requested service at the time of the request.

The rule applies to preauthorization requests for exempt services.

Billing Rule

Ordering Provider Information Required

Claims from treating physicians or providers must include the name and NPI of the ordering physician or provider. If this ordering-provider information is omitted, Sendero cannot waive the preauthorization requirement, and the claim will deny unless a medical-necessity approval preauthorization is in place.

CMS-1500: report the information in fields 17 and 17B.
UB-04: report the information in fields 76-79 or another appropriate field.
Electronic claims: report the information in the corresponding ASC X12N 837 fields.

Prior Authorization

Post-Acute Care Requests

A preauthorization request for post-acute care must include the name and NPI of the treating provider from the referring facility who determined that post-acute care is needed and is requesting the preauthorization.

The required provider is the treating provider from the referring facility who made the post-acute-care decision and submitted the request.