Prior Authorization

Use our tool to see if a pre-authorization is needed. It's quick and easy. If an authorization is needed, you can access our login to submit online.

Pre-Auth Needed Tool - Ambetter | Medicaid | Medicare Advantage | STAR+PLUS MMP

Please note that failure to obtain authorization may result in administrative claim denials. Superior HealthPlan providers are contractually prohibited from holding any member financially liable for any service administratively denied by Superior for the failure of the provider to obtain timely authorization.

Check to see if a pre-authorization is necessary by using our online tool. Select a product line to get started.

Click on the links below for more information.

As the medical home, PCPs should coordinate all health-care services for Superior members. PCPs are required to refer a member to a specialist when medically-necessary care is needed beyond the scope of the PCP.  Referral to out-of-network providers will be made when medically-necessary to do so. All out-of-network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical records.

Some services require prior authorization from Superior in order for reimbursement to be issued to the provider. To view our product lists, use our Prior Authorization Prescreen Tool - Ambetter | Medicaid | Medicare Advantage | STAR+PLUS MMP.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date, or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admittance date.

Superior will process most routine authorizations within five (5) business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to fourteen (14) calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email or secure web portal.

Superior’s Medical Management department hours of operation are Monday through Friday from 8:00 a.m. to 5:00 p.m., CST (excluding holidays). After normal business hours, Superior’s nurse advice line staff is available to answer questions and intake requests for prior authorization by calling 1-800-783-5386. 

Superior HealthPlan has contracted with National Imaging Associates Inc. (NIA), an affiliate of Magellan Health Services, for radiology benefit management.

The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Superior oversees the NIA program and is responsible for claims adjudication. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.

Prior authorization is required for the following outpatient radiology procedures:

  • CT/CTA/CCTA
  • MRI/MRA
  • PET Scan

KEY PROVISION:

  • Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.

Visit the NIA website for more information.