Prior Authorization & Referrals

Some medical services require approval from Superior HealthPlan. This is called prior authorization. Below is a list of services that require prior authorization from your doctor before you can get them. 

Prior Authorization

Pre-scheduled, optional services must be approved by Superior before you are admitted. Your provider will send a request to Superior. Superior must be notified by the end of the next business day if you are admitted to an inpatient facility.

Requests for services from a provider, facility, or vendor that is not in the Superior network need to be approved.

In case of emergency, you should get medical care right away and then you or the doctor should call Superior as soon as possible.

  • Chiropractor
  • Oral Surgeon*
  • Plastic and Reconstructive Surgery*
  • Podiatry*

*NOTE: Office visits do not need approval, but services done in any other location do need approval.

All evaluations need approval and must be given to Superior by your provider. Your provider must sign the treatment plan.

  • Speech, Occupational and Physical Therapy*
  • Pulmonary and Cardiac Rehab
  • Cognitive Rehabilitation Therapy

*NOTE: Therapy given by an Early Childhood Intervention (ECI) Provider as part of an Individual Family Service Plan (IFSP) does not need to be approved.

  • Abortion
  • Bariatric Surgery (weight loss)
  • Blepharoplasty (eyelid plastic surgery)
  • Dental Anesthesia
  • Circumcision 1 year and older
  • Hysterectomy
  • Infertility
  • Implantable devices including Cochlear Implant
  • Mammoplasty (breast augmentation surgery)
  • Otoplasty (ear plastic surgery)
  • Rhinoplasty or Septoplasty (nose plastic surgery)
  • Scar Revision/Excision of Lesion
  • Treatment of Varicose Veins
  • Vagus Nerve Stimulation

All services for Transplant Evaluation and Transplant Procedures.

  • Computerized Tomography (CT)
  • Computerized Tomography Angiography (CTA)
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Angiogram (MRA)
  • Positron Emission Tomography (PET)
  • Cardiac Computed Tomography Angiography (CCTA), Stress Echo, Echocardiography (only for STAR+PLUS) and Nuclear Cardiology
  • Air transport
  • Non-emergent ambulance, including transportation between facilities

Injectables greater than $100 given in an outpatient setting. This does not include some medications for chemotherapy or dialysis.

  • Personal Attendant Services (PAS)
  • Day Activity and Health Services (DAHS)
  • Personal Attendant Services (PAS)
  • Day Activity and Health Services (DAHS)
  • Nursing Services (In Home)
  • Emergency Response Services (ERS)
  • Home Delivered Meals (HDM)
  • Minor Home Modifications (MHM)
  • Assisted Living (AL)
  • Transition Assistance Services (TAS)
  • Adult Foster Care (AFC)
  • Durable Medical Equipment (DME) over $500
  • Enteral Nutrition (tube feeding)
  • Genetic Testing
  • Quantitative Testing for Drugs and Abuse
  • Home Health/Skilled Nursing/Private-Duty Nursing
  • Hearing Aids
  • Nutritional Counseling (approval is not needed when this is part of a Texas Health Steps exam or for ECI assessment)
  • Obstetric (OB) Ultrasounds: Members are limited to 3 ultrasounds for a pregnancy that is not high-risk without being approved. Approval is not needed for any high-risk pregnancy ultrasounds
  • Orthotics/Prosthetics over $500
  • Allergen Immunotherapy Services: Unless services are given by an allergist or immunologist
  • Pain Management Services: All providers need approval for any service done managing pain
  • Sleep Study
  • Telemonitoring

The following is a list of some of the services not covered by Superior:

  • Services or items only for cosmetic purposes
  • Items for personal cleanliness and grooming
  • Services decided to be experimental or for research
  • Sex change operations
  • Services not approved by the Primary Care Provider, unless the Primary Care Provider approval is not needed (i.e. family planning, Texas Health Steps and behavioral health)
  • Care that is not medically necessary
  • Abortions except as allowed by state law
  • Infertility services

Specialists

Your doctor might want you/your child to see a special doctor (specialist) for certain health-care needs. While you/your child’s doctor can take care of most of your health-care needs, sometimes they will want you/your child to see a specialist for your care. A specialist has received training and has more experience taking care of certain diseases, illnesses and injuries. Superior has many specialists who will work with you and your doctor to care for your needs. In some situations, the specialist may see you/your child right away. Depending on the medical need, it may take up to a few weeks after you make the appointment to see the specialist.

Referrals

The doctor will talk to you about your/your child’s needs and will help make plans for you to see the specialist that can provide the best care for you. This is called a referral. Your/your child’s doctor is the only one that can give you a referral to see a specialist. If you/your child has a visit, receives services from a specialist without your doctor’s referral, or if the specialist is not a Superior provider, you might be responsible for the bill. In some cases, an OB/GYN can also give you a referral for related services.

Some specialist referrals from your/your child’s doctor may need approval from Superior to make sure the specialist is a Superior specialist, and the visit to the specialist or the specialty procedure is needed. In these cases, the doctor must first call Superior. If you or your doctor are not sure what specialty services need approval, Superior can give you that information. Superior will review the request for specialty services and respond with a decision. This will not take more than two (2) business days after getting all the needed information from your doctor. Decisions are made more quickly for urgent care.

You do not need a referral for:

  • True emergency services
  • OB/GYN care.
  • Behavioral health services.
  • Routine vision services.
  • Dental services (for children).
  • Family planning services.