Complaint Procedures

Superior recognizes that there are times when a provider may not be satisfied with a matter handled by Superior. Providers have the right to file a complaint related to that matter. The Complaint Procedures page will describe the process to file a complaint, the response timeframes and the complainant’s rights during the process. The complaint process does not include appeals for determinations/actions based on medical necessity. Appeals for determinations based on medical necessity are outlined in the Provider Manual.

A complaint is an expression of dissatisfaction communicated by a complainant, orally or in writing, about any matter related to Superior, other than an action/adverse determination. As provided by 42 C.F.R. §438.400, possible subjects for complaints include, but are not limited to:

  1. The quality of care of services provided;
  2. Aspects of interpersonal relationships such as rudeness of a provider or employee, or
  3. The failure to respect the Medicaid member’s rights. 

Superior requires that all complaints received from providers be submitted to Superior in writing. Superior offers a number of ways to file a written complaint, as listed below:

  • Online through Superior’s Complaint Form
  • Faxing or mailing a complaint form to Superior for a resolution response. 
  • Mailing or faxing a written complaint to the following:
    Superior HealthPlan
    ATTN: Complaint Department
    5900 E. Ben White Blvd.
    Austin, Texas 78741
    Fax: 1-866-683-5369
  • Calling Provider Services at:
Product Phone
STAR, STAR+PLUS, CHIP, STAR Kids 1-877-391-5921
STAR MRSA 1-877-644-4494
CHIP RSA 1-800-522-8923
STAR Health 1-866-439-2042

For help filing a provider complaint or to check on the status of a provider complaint, providers may email TexasProviderComplaints@centene.com.

When a complaint is received, a written acknowledgement letter is sent to the provider within five (5) business days of receipt of the complaint. Superior then has thirty (30) calendar days to resolve the complaint. The response to the complaint will be provided in writing in the form of a resolution letter. If the resolution/response is not satisfactory, a complaint appeal may be filed.

Superior maintains all documentation (fax, electronic and telephonic) related to the receipt and response to the complaint, to include routing and correspondence maintenance, within the current software solutions used for complaints processing. The system used accommodates a secure and complete record of each complaint and any complaint proceedings or actions taken on a complaint/complaint-appeal according to minimum record retention requirements.

Superior will maintain documentation on each complaint/appeal until five (5) years after the termination of the contract with the Health and Human Services Commission. Such documentation for each complaint/appeal filed includes date of receipt, identification of the individual filing the complaint/appeal, all documentation pertaining to the complaint/appeal, identification of the individual recording the complaint/appeal, the substance and nature of the complaint/appeal, investigation details and the disposition and resolution of the complaint/appeal and the date resolved.

Medicaid providers may file a complaint with HHSC after exhausting Superior’s complaint procedures by submitting to HPM_Complaints@hhsc.state.tx.us and for STAR Health STAR.Health@hhsc.state.tx.us or:

Texas Health and Human Services Commission
Health Plan Management – H-320
P.O. Box 85200
Austin, TX 78708-5200

CHIP providers also have the right to complain to the Texas Department of Insurance (TDI) after exhausting Superior’s complaint procedures by contacting TDI at:

Texas Department of Insurance
Consumer Protection Mail Code 111-1A
P.O. Box 149091
Austin, Texas 78714-9091

It is important to note that inquiries or appeals related to claims are handled separately from provider complaints. Please review the Superior Provider Manual for the process for claims inquiries and appeals. Claim status can be viewed via the Superior web portal as well. For claims status inquiries or appeals, contact Superior’s Provider Services claims hotline at:

Product Phone
STAR, STAR+PLUS, STAR+PLUS MMP, CHIP, Medicare Advantage 1-877-391-5921
STAR KIDS (effective 11/1/16) 1-844-878-2252
STAR MRSA 1-877-644-4494
CHIP RSA 1-800-522-8923
STAR Health (Foster Care) 1-866-439-2042

The complaint process does not include medical necessity appeals that are directed to the plan’s Medical Management Department. Please refer the Superior Provider Manual for details related to medical necessity denials and appeal. Medical necessity appeals are submitted to Superior to:

Superior HealthPlan
Attention: Appeals/Denials Coordinator
5900 E. Ben White Blvd.
Austin, Texas 78741
PHONE: 1-877-398-9461
FAX: 1-866-918-2266

Please note: Appeals must be submitted to the Superior appeals mailing address, however participating or non-participating providers may use the appeals email address to file or check the status of a pre-service appeal for any product line at MMPAppeals_Grievances@centene.com.

Providers may appeal claim recoupment by submitting the following information to HHSC:

  • A letter indicating that the appeal is related to a managed care disenrollment or retro-eligibility recoupment and that the provider is requesting an Exception Request.
  • The Explanation of Benefits (EOB) showing the original payment. Note: This is also used when issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an authorization for the exact items that were approved by the plan.
  • The EOB showing the recoupment and/or the plan’s “demand” letter for recoupment. If sending the demand letter, it must identify the client name, identification number, DOS and recoupment amount. The information should match the payment EOB.
  • Completed clean claim. All paper claims must include both the valid NPI and TPI number. Note: In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted with the authorization number and the provider will need to submit a corrected claim that contains the valid authorization number. Mail appeal requests to:
    Texas Health and Human Services Commission
    HHSC Claims Administrator Contract Management, Mail Code-91X
    P.O. Box 204077
    Austin, Texas 78720-4077

Members may file complaints to Superior verbally or in writing, at any time. There are a variety of ways in which a member complaint can be filed. Verbal complaints will be accepted via our toll-free number (below) or face-to-face. Members may call the Member Services Department to file a complaint regarding dissatisfaction with Superior. Superior’s Member Services Departments can be reached at:

Product Phone
STAR, CHIP 1-800-783-5386
STAR MRSA 1-877-644-4494
CHIP RSA 1-800-820-5685
STAR Health 1-866-912-6283
STAR Kids (Effective 11/1/16) 1-844-590-4883
STAR+PLUS 1-866-516-4501
STAR+PLUS MMP 1-866-894-1844
Medicare Advantage 1-877-935-8023
Ambetter 1-877-687-1196

For written complaints, a member can file a complaint online through Superior’s website by clicking here. A Superior Member Advocate can help file a complaint or appeal. A written complaint can also be mailed or faxed to:

Superior HealthPlan
ATTN: Complaince Department
5900 E. Ben White Blvd.
Austin, Texas 78741
Fax: 1-866-683-5369

When a complaint is received, a written acknowledgement letter is sent to the complainant within five (5) business days of receipt of the complaint. Superior then has thirty (30) calendar days to resolve the complaint. The response to the complaint will be provided in writing in the form of a resolution letter. If the resolution/response is not satisfactory, a complaint appeal may be filed.

The complaint appeal process is initiated when the plan receives a written request for appeal. The complaint appeal process includes a panel hearing in which the member’s dissatisfaction with the complaint response is reviewed. The panel consists of equal numbers of members, providers and Superior staff. The panel is conducted, and a final resolution on the complaint is completed within thirty (30) calendar days after the date of receipt of the written request for complaint appeal.

If a Medicaid member is not satisfied with the outcome of the appeal, they can file a complaint with the Health and Human Services Commission (HHSC) at 1-866-566-8989 or by mail at the address below.

Texas Health and Human Services Commission
Health Plan Management – H-320
Attn: Resolution Services
P.O. Box 85200
Austin, TX 78708-520

Medicaid members can file a complaint through the Office of Long Term Care Ombudsman by calling toll free at 1-800-252-2412, emailing the Texas Department of Aging and Disability Services at mail@DADS.state.tx.us or by visiting http://www.dads.state.tx.us/contact/mlo.cfm.

CHIP members are required to file complaints in writing. They may call the Member Services Department to request a complaint form. Superior’s Member Services Departments can be reached at:

Product Phone
CHIP 1-800-783-5386
CHIP RSA 1-800-820-5685

Members can also file a written complaint online through Superior’s website by clicking here. A Superior Member Advocate can help file a complaint or appeal. A written complaint can also be mailed or faxed to:

Superior HealthPlan
ATTN: Complaint Department
5900 E. Ben White Blvd.
Austin, Texas 78741Fax: 1-866-683-5369

It is Superior’s goal to resolve all complaints in a timely manner. When a complaint is received, a written acknowledgment is sent to the member within five (5) business days. Superior has thirty (30) calendar days to resolve any complaint received. If the member is not satisfied with the resolution, the member may appeal the complaint response. Complaint appeals must be submitted in writing.

The appeal process includes a panel hearing in which the member’s dissatisfaction with the complaint response is reviewed. The panel consists of equal numbers of members, providers and Superior staff. The panel is conducted, and a final resolution on the complaint is completed within thirty (30) calendar days after the date of receipt of the written request for complaint appeal.

CHIP members also have the right to complain to the Texas Department of Insurance (TDI) by calling toll free 1-800-252-3439 or contacting them in writing at:

Texas Department of Insurance
Consumer Protection Mail Code 111-1A
P.O. Box 149091
Austin, Texas 78714-9091

 

An appeal is the request for review of a “Notice of Adverse Action.”  A “Notice of Adverse Action” is considered the denial or limited authorization of a requested service, including:

  • The type or level of service;
  • The reduction, suspension, or termination of a previously authorized service;
  • The denial, in whole or part, of payment for a service excluding technical reasons;
  • The failure to render a decision within the required timeframes; or
  • The denial of a member’s request to exercise his/her right to obtain services outside the Superior network.  

The review may be requested orally or in writing; however, oral requests for appeals within the standard timeframe must be resolved within thirty (30) days of receipt of the appeal, with a 14-day extension possible if additional information is required. Members may request that Superior review the “Notice of Adverse Action” to verify if the right decision has been made. Expedited appeals may be filed when either Superior or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or his/her ability to attain, maintain or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.

Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding seventy-two (72) hours from the initial receipt of the appeal. For any extension not requested by the member/provider, Superior shall provide written notice to the member of the reason for the delay. Superior shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two  calendar days with a written notice of action.