Complaints and Appeals
Filing a Complaint
If you are unhappy with Superior, you may file a complaint. Complaints may be made by calling Superior Member Services at the number on the back of your ID card (Relay Texas 1-800-735-2989). A complaint acknowledgement letter will be sent to you within five (5) days, along with an oral complaint form. This form needs to be completed and returned to Superior for us to proceed with the processing of your complaint. If you have questions, we can help you complete the form. Written complaints can be sent on paper or electronically. To file your complaint, send to:
5900 E. Ben White Blvd.
Austin, TX 78741
You may also file your complaint online by filling out a complaint form.
You can call us if you have questions about the complaint process or the status of your complaint. Call Member Services at the number on the back of your ID card.
You will be notified within five (5) business days that the complaint has been received. Expedited complaints concerning emergencies or denial of continued hospitalization will be resolved within one business day from receipt of the complaint or earlier depending on the medical immediacy of the case. You will receive a letter with the resolution to your complaint within three (3) business days.
Members submitting non-expedited complaints will receive a letter with the resolution within thirty (30) calendar days of receipt of the complaint. If you are not satisfied with the complaint resolution, within thirty (30) days, you can request an appeal of the complaint resolution. In response to your complaint appeal, a complaint appeal panel including Superior staff, provider(s) and member(s) will be held at a location in your area, upon request. A hearing packet will be sent to you five (5) days before the appeal panel hearing is held. You may attend the hearing, have someone represent you at the hearing or have a representative attend the hearing with you. The panel will make a recommendation for the final decision on your complaint, and Superior’s final decision will be provided to you within thirty (30) days of your complaint appeal request.
If you receive benefits through Medicaid’s STAR, STAR+PLUS, STAR Health or STAR Kids program, call your medical or dental plan first. If you don’t get the help you need there, you should do one of the following:
- Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).
- Online: Online Submission Form (only works in Internet Explorer)
Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
- Fax: 1-888-780-8099 (Toll-Free)
You may also file a complaint with the Texas Department of Insurance (TDI). There are several ways to file a complaint with TDI:
- Visit www.tdi.texas.gov and fill out a complaint form.
- Send an email to ConsumerProtection@tdi.texas.gov
- Mail your complaint to:
Texas Department of Insurance
Consumer Protection Section (MC 111-1A)
P.O. Box 149091
Austin, TX 78714-9091
Superior will never retaliate against you because you filed a complaint against us, or appealed our decision. Similarly, we will never retaliate against a physician or provider because the provider has, on your behalf, filed a complaint against us or appealed a decision.
Filing an Appeal
When do I have the right to ask for an appeal?
You have the right to appeal Superior’s decision if Medicaid covered services are denied based on lack of medical need. Superior’s denial is called an “action” or “adverse determination.” You can appeal the action 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.
- Has not paid a hospital bill you think we should pay (claim appeal).
- Limits a request for a covered service.
You, a doctor or someone else acting on your/your child’s behalf can appeal an action.
Can someone from Superior help me file an 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.
What are the timeframes for the appeals process?
Medicaid and CHIP members will have sixty (60) calendar 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 thirty (30) calendar days. This process can be extended up to fourteen (14) calendar days if you ask for an extension. If more time is needed to gather facts about the requested service, you will receive a letter with the reason for the delay.
How can I ask for continuity of current authorized services?
If you are receiving a service that is being ended, suspended or reduced, you must file an appeal on or before the later of ten (10) days following Superior’s mailing of the denial letter (ten  days from the postage stamp date on the envelope), or on the intended effective date of the proposed action.
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.
Call Superior Member Services for more information.
Does my request have to be in writing?
You can call us to let us know you want to appeal an action, but you must follow up your phone call with a request in writing, unless an expedited appeal is requested. If you need help, Superior can help you put your appeal in writing. Just call Member Services.
You can send an appeal in writing to:
ATTN: Medical Management
5900 E. Ben White Blvd.
Austin, Texas 78741
What is an expedited appeal?
An expedited 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 expedited appeal? Does my request have to be in writing?
You can ask for an expedited appeal by calling Superior’s Medical Management department at 1-877-398-9461. You can also ask for an expedited appeal in writing and send it to Superior’s Medical Management department at:
ATTN: Medical Management
5900 E. Ben White Blvd.
Austin, Texas 78741
Expedited appeals do not have to be in writing.
Who can help me file an expedited appeal?
Superior’s Member Advocates can help you with your expedited appeal. You can also have your doctor, a friend, a relative, lawyer or another spokesperson help you.
What are the timeframes for an expedited appeal? What happens if Superior denies my request for an expedited appeal?
If your request for an expedited appeal is approved, the following timeframes apply. If your appeal is about an ongoing emergency or denial to continue a hospital stay, Superior will make a decision about your expedited appeal within one (1) business day. Other expedited appeals will be decided within three (3) calendar days. This process can be extended up to fourteen (14) calendar days if more facts are needed. If Superior thinks your appeal does not need to be expedited, Superior will let you know right away. The appeal will still be worked on but the resolution may take up to thirty (30) days.
What is an Independent Review Organization (IRO)? (CHIP MEMBERS ONLY)
An Independent Review Organization (IRO) is an outside organization that the Texas Department of Insurance (TDI) picks to review your health plan’s denial of a service you and your doctor feel is medically necessary. This organization is not related to your doctor or to Superior. There is no cost to you for this independent review.
You can ask for a review by an IRO 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 a review by an Independent Review Organization? (CHIP MEMBERS ONLY)
To ask for an IRO, you must fill out the “Request for a Review by an Independent Review Organization” form that is sent with the denial letter.
What are the timeframes for this process? (CHIP MEMBERS ONLY)
Once you return the form to Superior, Superior will send your request immediately to TDI. TDI will assign an IRO within one working day. TDI will let you and Superior know who the IRO is. Superior will then send all of the records on your case to the IRO no later than the third working day after your request for an IRO. The IRO will make a decision in no more than fifteen (15) days from the date they receive all of the facts from Superior about your case. The IRO will send you a letter that will let you know what they decide. Superior must follow the decision of the IRO.
If your case is a life-threatening condition, the IRO’s decision will happen more quickly.
State Fair Hearings
If you disagree with Superior’s appeal decision, you have the right to ask for a Medicaid State Fair Hearing from the Texas Health and Human Services Commission (HHSC) You may represent yourself at the 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 Fair Hearing within 120 days of the date this notice. HHSC can extend this deadline if you have a good reason for being late.
If we’re stopping or reducing a service, you can keep getting the service while your case is being reviewed. To qualify, you must ask for a Fair Hearing within 10 days of the date of this notice or before the service is stopped or reduced, whichever is later.
To ask for a Fair Hearing, you or your representative should write or call Superior at 1-877-398-9461; 5900 E. Ben White Blvd., Austin, TX 78741.
If you believe that waiting for a 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 expedited Fair Hearing by writing or calling Superior. To qualify for an expedited Fair Hearing through HHSC, you must have completed Superior’s internal expedited appeals process.
If you ask for a 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 HHSC hearings 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.
HHSC will give you a final decision within 90 days from the date you asked for the hearing.