Complaints and Appeals

When do I have the right to ask for an internal health plan appeal?

Superior will send you a letter if a requested service that requires authorization is denied or limited. You have the right to appeal Superior’s decision if Medicaid covered services that require authorization are denied, reduced, suspended or ended. You may also appeal Superior’s denial of a claim, in whole or in part. Superior’s denial is called an “Adverse Benefit Determination.” You can appeal the Adverse Benefit Determination if you think Superior:

• Is stopping coverage for care you think you/your child needs.
• Is denying coverage for care you think should be covered.
• Provides a partial approval for a covered service.

You, a provider or someone else acting on your/your child’s behalf can appeal an action.

You can ask for an internal health plan appeal within 60 Days from the date of Superior’s Notice of Adverse Benefit Determination letter.

Can someone from Superior help me file an internal health plan appeal? Who do I call if I have questions about my appeal?

A Superior Member Services Advocate can help you file an appeal or answer questions about the status of an appeal. Just call Member Services.

Product	Phone
STAR/CHIP	1-800-783-5386
STAR Health	1-866-912-6283
STAR+PLUS	1-877-277-9772
STAR Kids	1-844-590-4883

What are the timeframes for the internal health plan appeals process?

Medicaid members will have sixty (60) calendar days from the date of Superior’s Notice of Adverse Benefit Determination letter to appeal the decision. Superior will acknowledge your appeal within five (5) business days of receipt, complete the review of the appeal, and send you an appeal response letter within thirty (30) calendar days after receipt of the initial written or oral request for appeal.

An additional 14 days may be added to process the appeal, if you request an extension or Superior shows that there is a need for additional information and how the delay is in the member’s interest. If more time is needed to gather facts about the requested service, you will receive a letter with the reason for the delay. If you do not agree with Superior’s decision to extend the timeframe for the decision on your appeal, you can file a complaint.

How can I ask for continuity of current authorized services while my appeal is pending?

You can ask to continue current authorized services when you appeal Superior’s Adverse Benefit Determination. To continue receiving a service that is being ended, suspended or reduced, your request to continue a service must be made within ten (10) calendar days of the date of Superior’s Notice of Adverse Benefit Determination letter, or before the date services currently authorized will be discontinued, whichever is later.

Superior will keep providing the benefits while your appeal is being reviewed, if:

• Your appeal is sent in the required time frame.
• Your appeal is for a service that was denied or limited that had been previously approved.
• Your appeal is for a service ordered by a Superior approved provider.

If Superior continues or reinstates benefits at your request and the request for continued services is not approved on appeal, Superior will not pursue recovery of payment for those services without written permission from HHS.

Call Superior Member Services for more information.

Does my internal health plan appeal request have to be in writing?

You can call or request in writing to let us know you want to appeal an Adverse Benefit Determination. You, your provider, a friend, a relative, lawyer or another spokesperson can request an appeal and complete the appeal form on your behalf. If you have questions about the appeal form, Superior can help you. Call Superior at 1-877-398-9461 to request an appeal by phone, or call Member Services at 1-800-783-5386 for more information.

You can send an internal health plan appeal in writing to:

Superior HealthPlan
ATTN: Medical Management
5900 E. Ben White Blvd.
Austin, Texas 78741

FAX: 1-866-918-2266

What is an internal health plan emergency appeal?

An internal health plan emergency appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

How do I ask for an internal health plan emergency appeal? Does my request have to be in writing?

You, your provider, or your legal authorized representative can ask for an emergency appeal by calling Superior’s Medical Management department at 1-877-398-9461. You can also ask for an emergency appeal in writing and send it to Superior’s Medical Management department at:

Superior HealthPlan
ATTN: Medical Management
5900 E. Ben White Blvd.
Austin, Texas 78741

FAX: 1-866-918-2266

Emergency appeals do not have to be in writing.

If you are eligible for both Medicare and Medicaid and need to request an emergency appeal for Medicare acute care services, please follow the expedited review process for your Medicare Plan/Program.

Who can help me file an internal health plan emergency appeal?

Your provider, a friend, a relative, lawyer or another spokesperson can file an internal health plan emergency appeal on your behalf. A Superior Member Advocate can help you with any questions you have about filing an emergency appeal.

What are the timeframes for an internal health plan emergency appeal?

We will notify you of the emergency appeal decision within 72 hours, unless your appeal is related to an ongoing emergency or denial of continued hospitalization. You will be notified of the appeal decision within one (1) business day for denials of on-going emergency or denial of continued hospital stay.

What happens if Superior denies my request for an internal health plan emergency appeal?

If Superior thinks that your emergency appeal request does not meet the emergency appeal criteria, Superior will let you know right away. Your appeal will be processed as a standard appeal with a response provided within 30 days.

After a Medicaid member has completed the internal health plan appeal process related to an adverse benefit determination, more appeal rights are available to a member if he/she is not satisfied with the health plan’s appeal decision.  After the health plan’s appeal decision is completed, members have additional external appeal rights, including a State Fair Hearing, with or without an External Medical Review. The details for both the State Fair Hearing and External Medical review appeal rights and process are included in the sections below.

EXTERNAL MEDICAL REVIEW

If you, as a member of Superior, disagree with our internal appeal decision, you have the right to ask for an External Medical Review. An External Medical Review is an optional, extra step you can take to get the case reviewed before the State Fair Hearing occurs. You may name someone to represent you by writing a letter to Superior telling us the name of the person you want to represent you. A provider may be your representative. You or your representative must ask for the External Medical Review within 120 days of the date Superior mails the letter with the internal appeal decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review. To ask for an External Medical Review, you or your representative may either:

• Fill out the ‘State Fair Hearing and External Medical Review Request Form’ provided as an attachment to the Member Notice of Superior’s Internal Appeal Decision letter and mail or fax it to Superior by using the address or fax number at the top of the form; or
• Call Superior at 1-877-398-9461

If you ask for an External Medical Review within 10 days from the time you get the appeal decision from Superior, you have the right to keep getting any service Superior denied, based on previously authorized services, at least until the final State Fair Hearing decision is made. If you do not request an External Medical Review within 10 days from the time you get the appeal decision from Superior, the service Superior denied will be stopped.

An Independent Review Organization is a third-party organization contracted by HHS that conducts an External Medical Review related to Adverse Benefit Determinations based on functional necessity or medical necessity. You may withdraw your request for an External Medical Review before it is assigned to an Independent Review Organization or while the Independent Review Organization is reviewing your External Medical Review request. An External Medical Review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.

Once the External Medical Review decision is received, you have the right to withdraw the State Fair Hearing request. If you continue with the State Fair Hearing, you can also request the Independent Review Organization be present at the State Fair Hearing. You can make both of these requests by contacting Superior at 1-877-398-9461 or the HHS Intake Team at EMR_Intake_Team@hhsc.state.tx.us.

If you continue with a State Fair Hearing and the State Fair Hearing decision is different from the Independent Review Organization decision, it is the State Fair Hearing decision that is final. The State Fair Hearing decision can only uphold or increase your benefits from the Independent Review Organization decision.

Can I ask for an emergency External Medical Review?

If you believe that waiting for a standard External Medical Review will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you, your parent or your legally authorized representative may ask for an emergency External Medical Review and emergency State Fair Hearing by writing or calling Superior HealthPlan. To qualify for an emergency External Medical Review and emergency State Fair Hearing review, you must first complete Superior’s internal appeals process.

STATE FAIR HEARING

How can I ask for a State Fair Hearing?

You must complete the internal health plan appeal process through Superior HealthPlan prior to requesting a State Fair Hearing. If you disagree with Superior’s appeal decision, you have the right to ask for a Medicaid State Fair Hearing from Texas Health and Human Services (HHS) with or without an External Medical Review through an Independent Review Organization (IRO). You can ask for an External Medical Review and a State Fair Hearing, but you cannot request only an External Medical Review. You may also request a State Fair Hearing with or without an External Medical Review if Superior does not make a decision on your appeal within the required time frame. You may represent yourself at the State Fair Hearing, or name someone else to be your representative. This could be a doctor, relative, friend, lawyer, or any other person. You may name someone to represent you by writing a letter to Superior telling them the name of the person that you want to represent you.

You or your representative must ask for a State Fair Hearing within 120 days of the date of the notice telling you that we are denying your appeal with Superior.

You have the right to keep getting any service the health plan denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made if you ask for a State Fair Hearing by the later of: (1) 10 calendar days following the date the health plan mailed the internal appeal decision letter, or (2) the day the health plan’s internal appeal decision letter says your service will be reduced or end. If you do not request a State Fair Hearing by this date, the service the health plan denied will be stopped.

If Superior continues or reinstates benefits at your request and the request for continued services is not approved by the State Fair Hearing officer, Superior will not pursue recovery of payment for those services without written permission from HHS.

To ask for a State Fair Hearing, you or your representative should write or call Superior:

Superior HealthPlan
ATTN: State Fair Hearing Coordinator
5900 E. Ben White Blvd.,
Austin, TX 78741
1-877-398-9461

You can ask for a State Fair Hearing without an External Medical Review. 

What happens after I request a State Fair Hearing?

If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most hearings are held by telephone. You can also contact the HHS State Fair Hearing officer if you would like the hearing to be held in-person.

During the hearing, you or your representative can tell why you need the service or why you disagree with the Superior’s action. You have the right to examine, at a reasonable time before the date of the Fair Hearing, the contents of your case file and any documents to be used by Superior at the hearing. Before the hearing, Superior will send you all of the documents to be used at the hearing. It is important that you or your representative attend the State Fair Hearing in person or by phone.

HHS will give you a final decision within 90 days from the date you asked for the State Fair Hearing.

Can I ask for an Emergency State Fair Hearing?

To qualify for an emergency State Fair Hearing through HHS, you must have completed Superior’s internal appeals process. If you believe that waiting for a State Fair Hearing will seriously jeopardize your life or health, or your ability to attain, maintain, or regain maximum function, you or your representative may ask for an emergency State Fair Hearing by writing or calling Superior at 1-877-398-9461. The State Fair Hearing officer will provide a response on your expedited State Fair Hearing request within three (3) business days.

When do I have the right to ask for an appeal?

You have the right to appeal Superior’s decision if CHIP covered services are denied based on lack of medical need. Superior’s denial is called an “adverse benefit determination.” You can appeal the adverse benefit determination if you think Superior:

• Is stopping coverage for care you think you/your child needs.
• Is denying coverage for care you think should be covered.
• Provides a partial approval of a request for a covered service.

You, a doctor or someone else acting on your/your child’s behalf can appeal an adverse benefit determination.

What are the timeframes for the appeals process?

You will have 60 days from the date of the denial letter to appeal the decision. Superior will acknowledge your appeal within five (5) Business Days of receipt, and complete the appeal within 30 calendar days.

Does my request have to be in writing?

You can call us to let us know you want to appeal an adverse benefit determination or you can send your request in writing. If you need help, Superior can help you put your appeal in writing.

Can someone from Superior help me file an appeal?

 You, your provider or another person acting on your behalf can file an appeal. A Superior Member Advocate can help you with any questions you have about filing an appeal. You can call Member Services at 1-800- 783-5386 (TTY: 1-800-735-2989) with any questions. Interpreter services are provided free of charge, call Member Services for assistance.

What is an expedited appeal?

An expedited appeal is when Superior HealthPlan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health. Expedited appeals are available for a denial of emergency care, denial of a continued hospitalization, and denial of prescription drugs or intravenous infusions.

Who can help me in filing an expedited appeal?

You, your provider or another person acting on your behalf can file an appeal. A Superior Member Advocate can help you with any questions you may have related to an expedited appeal. You can call Member Services at 1-800-783-5386 with any questions.

How do I ask for an expedited appeal? Does my request have to be in writing?

You, your provider or another person acting on your behalf can ask for an expedited appeal by calling Superior’s Appeals team at 1-800-218-7453. You can also ask for an expedited appeal in writing and send it to Superior’s Appeal Department by fax at 1-866-918-2266.

What are the timeframes for an expedited appeal?

Superior will make a decision about your expedited appeal within one (1) Business Day, and send you a letter within 72 hours.

What is a specialty review?

Once an appeal is requested, your provider can ask for a specialty review. A specialty review is when your provider requests the review be completed by a particular type of specialist.

What are the timeframes for a specialty review?

Your provider can request a specialty review up to 10 working days after you file an appeal or your appeal is denied. The specialty review must be completed within 15 working days from the date your health care provider’s request is received.

What is an External Review?

An External Review is an outside review of your health plan’s denial of a service you and your doctor feel is medically necessary. The External Review process is managed by MAXIMUS Federal Services for CHIP members. This organization is not related to your doctor or to Superior. There is no cost to you for an External Review. You can ask for an External Review after you complete the appeal process with Superior, or if Superior has denied a service that you think is life threatening.

How do I ask for an External Review?

All External Review requests must be sent directly to MAXIMUS Federal Services, the External Review Organization for Superior CHIP members.

To request an External Review, you must provide the following information: name, address, phone number, email address, whether the request is expedited or standard, a completed Appointment of Representative Form (if someone is filing on your behalf) and a brief summary of the reason you disagree with Superior’s decision.

You must fill out the HHS Federal External Review Request Form (PDF) that is sent with the adverse benefit determination or appeal letter. Include your adverse benefit determination letter from Superior when mailing or faxing your request to MAXIMUS. If you need this form, Superior can provide a copy to you.

Send your request for External Review directly to MAXIMUS at:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

Fax number: 1-888-866-6190

What are the timeframes for this process?

The MAXIMUS Federal Services examiner will contact Superior immediately when they receive the request for External Review. Within five (5) Business Days, Superior will give the examiner all documents and information used to make the internal appeal decision.

For standard External Review request:

You or someone acting for you will receive written notice of the final External Review decision as soon as possible. You will receive notice no later than 45 days after the examiner receives the request for an External Review.

For expedited or fast External Review request:

The MAXIMUS examiner will give Superior and you or the person filing on your behalf the External Review decision as quickly as medical status requires. You will get a decision no later than 72 hours of us receiving the request. You or someone acting for you will receive the decision by phone. MAXIMUS will also send a written version of the decision within 48 hours of the phone call.