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Additional External Appeal Rights Available for Medicaid Members Starting May 1, 2022

Date: 03/31/22

Effective May 1, 2022, a STAR, STAR Health, STAR+PLUS or STAR Kids member may ask for an External Medical Review if the member disagrees with Superior’s internal health plan appeal decision. An External Medical Review is an optional, extra step a member can take to get the case reviewed for free before the State Fair Hearing. An Independent Review Organization (IRO), who is contracted with HHSC, will be making the External Medical Review decision. The IRO has clinical staff that will perform a review of Superior’s appeal records, based on functional necessity or medical necessity, to confirm that Superior made the right decision to deny the member’s appeal. A member cannot request an External Medical Review without also requesting a State Fair Hearing.

Requests for an External Medical Review and State Fair Hearing must be made by the member or the member’s representative within 120 calendar days of Superior’s internal health plan denied appeal decision. A member must exhaust Superior’s internal health plan appeal process before an External Medical Review and State Fair Hearing can be requested.

To ask for an External Medical Review and State Fair Hearing, the member or the member’s representative should 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;
  • Call Superior at 1-877-398-9461 or;
  • Go in-person to a local HHS office.

If a member wants to keep getting services that will be reduced, suspended or terminated as result of Superior’s denied appeal, the External Medical Review and State Fair Hearing must be requested within 10 calendar Days from the time the member gets the appeal denial decision letter from Superior. If the member requests to continue services, the services will continue, at least until the final State Fair Hearing decision is made.

If an External Medical Review is requested, the member will receive a letter from the IRO with their decision in fifteen (15) calendar days or less.  

If a member believes that Superior’s denied appeal will seriously jeopardize his or her life or health, or the ability to attain, maintain or regain maximum function, the member or their representative may ask for an Emergency Medical Review by writing or calling Superior. The IRO will respond to these requests within one (1) business day after Superior receives the member’s Emergency Medical Review request.

A member may withdraw his/her request for an External Medical Review, if the IRO has not completed their review of the member’s request. An External Medical Review cannot be withdrawn if an Independent Review Organization has already completed the review and made a decision.  

After the External Medical Review decision is received, a member has the right to withdraw the State Fair Hearing request. If a member continues with the State Fair Hearing, they can also request the Independent Review Organization be present at the State Fair Hearing. Both of these requests can be made by contacting Superior at 1-877-398-9461 or the HHS Intake Team at EMR_Intake_Team@hhsc.state.tx.us.