COB CLAIMS

For both Professional and Institutional claims submissions on the Secure web portal, providers have an additional question asking “Does the member have additional coverage?”. If “No” is selected, the provider can continue with the claim as normal. If ”Yes” is selected, the Coordination of Benefits section will be available at the next step of the claims submission.

Carrier type will be either “Medicare” or “Commercial” and there is also a required field to indicate if this is the “Primary” or “Secondary” Carrier. The Carrier Payment section contains fields for the Amount Allowed, Deductible, Copay, Co-Insurance, and Amount Paid. The Denied Reason section allows providers to select the reason along with the dollar amount to deny for each reason.

CORRECT CLAIM

From the Check Claims Status screen, search for a claim.

From the results, click on the Claim No. of the claim to be corrected.

To correct this claim, click on “Correct Claim” link on the upper left.

• Email: TX-ECI@centene.com
• Superior Health Plan

ATTN: Case Management – ECI
8431 Fredericksburg Road, Suite 340
San Antonio, Texas 78229

Discontinued
Q2042

Added
J1725

Limitations for added procedure codes: Medical services procedure code J1725 may be reimbursed to NP, CNS, PA, physician, and certified nurse midwife (CNM) providers for services rendered in the office setting; to DME medical supplier providers for services rendered in the home setting; and to hospital providers for services rendered in the outpatient hospital setting. Procedure code J1725 replaces procedure code J3490 with modifier TH and procedure code Q2042.

Procedure code J1725 may be reimbursed when billed with diagnosis code V2341.

Important: Procedure code J3490 with modifier TH will no longer be reimbursed for the compounded form of the hydroxyprogesterone caproate injection.

Providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, Section 8.2.37.4, “17-Alpha Hydroxyprogesterone Caproate,” for more information.

Wednesday, April 11th 2PM Eastern Daylight Savings Time (EDT)
https://www2.gotomeeting.com/register/319298554

Thursday, April 12th 10AM Eastern Daylight Savings Time (EDT)
https://www2.gotomeeting.com/register/473977082

Thursday, April 12th 4PM Eastern Daylight Savings Time (EDT)
https://www2.gotomeeting.com/register/305009642

Friday, April 13th NOON Eastern Daylight Savings Time (EDT)
https://www2.gotomeeting.com/register/697502722

ATTN: All Providers

Effective 6-1-2012 the following Genetic Testing Codes will require authorization.

You may request authorization by Web Portal, www.superiorhealthplan.com, Fax, 800-690-7030, or phone, 800-218-7508.

Genetic Testing Codes Authorization Required

Do you want to be? Do you want to understand more? Let Superior Help! Click here for more information on the Texas Health Steps program and available resources. You can also contact your local Provider Relations Representative for information about your practice and ways we can help you increase your exam rate!

As a result, Superior is making improvements to our medical necessity criteria for therapy services, which will facilitate more specificity and clarity to each discipline. All therapy services must be authorized through Superior, 5 business days prior to start of services. To assist you, the guidelines for requesting therapy services for Superior Members are attached for your information and reference.

Requests for therapy can be made by phone, fax, or web by contacting Superior at:

• Phone: 1-800-218-7508
• Fax:     1-800-690-7030
• Web: www.superiorhealthplan.com

Initial evaluations and re-evaluations do not require an authorization, but claim must be submitted with MD evaluation order.

• For initial therapy requests, Physician script (signed by PCP, Neurologist, Orthopedic Physician, or Rehabilitation Physician) and a Plan of Care must be submitted which includes:
  • A brief history of therapy treatment;
  • A description of the Member’s current level of functioning or impairment, and identification of any known primary or secondary health conditions;
  • A clear diagnosis and reasonable prognosis;
  • Prescribed treatment modalities, their anticipated frequency and duration; dates of service; and
  • Short and long-term Treatment Goals.

• For ongoing therapy requests, Physician script (signed by PCP, Neurologist, Orthopedic Physician, or Rehabilitation Physician) and an updated Plan of Care must be received prior to the end of each authorized period of treatment, to include:
  • Objective measures of the Member’s progress relative to each Treatment Goal, and a comparison to the previous Progress Report;
  • An explanation of any changes to the Member’s Plan of Care, and the clinical rationale for revising the Plan.
  • Prescribed treatment modalities, their anticipated frequency and duration, and dates of service.

• Frequency of Treatment – May be approved according to the clinical rationale for initiating or continuing treatment within a reasonable and medically predictable period of time. Up to six (6) months of treatment may be requested and authorized, when determined medically necessary and the medical prognosis is clinically supported.
  • Mild Developmental Delays = Up to 1x per week (max DOS approval will be 3 months)
  • Moderate Developmental Delays = Up to 2x per week (max DOS approval will be 3 months)
  • Severe Developmental Delays = Up to 3x per week (max DOS approval will be 6 months)

• Children with Developmental Delays – There is a Federal mandate (IDEA) for Children between the ages of (3-21) to be evaluated and/or treated in a school-based setting when a Developmental Delay or impairment impacts the Child’s ability to access the General Education Environment. Provider Requests for treatment services which seek to supplant those services identified and/or authorized by a School/District will be referred back to the School/District if services duplicate, supplement, or replace services that are the legal responsibility of other entities or institutions.

• Early Childhood Intervention (ECI) – Superior educates its network providers that any Members birth through 35 months, suspected of having a developmental disability or delay, are referred to the designated ECI program for screening and assessment. Superior does not require prior authorization for the ECI assessment, and permits Members to self refer to local ECI Service Providers.

Please contact Superior with any questions about the guidelines and information contained herein at 1-877-391-5921. These guidelines will be effective 3-1-2012.

For claims that are in process, the claim status may change throughout the processing.  Until a “PAID” or “DENIED” status shows, the final outcome of the claim has not been determined in the system.