Providing Quality Care

The Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) and the Outpatient Mental Health Survey (OPMH) offer patients opportunities to report their satisfaction with their healthcare, including their experience with their practitioners, providers, and the health plan. Survey results are used to determine patient and member satisfaction, their likelihood of staying with their practitioner, provider, or health plan, and identify opportunities to improve satisfaction with their healthcare. 

You are essential to providing the highest-quality healthcare possible for members, and your satisfaction is equally important. Superior assesses your experience with the plan through an annual Provider Satisfaction Survey. These survey results are key to helping improve the provider experience. Your feedback informs improvement opportunities and quality initiatives, so please be sure to complete the survey if you receive one. 

During the credentialing process, Superior obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. Please review your provider manual regarding this correction process. You also have the right to review the status of your credentialing or re-credentialing application at any time by calling your Provider Engagement Representative. You also have the right to review the status of your credentialing or recredentialing application by by contacting Superior's Credentialing Department at 1-800-820-5686 or Credentialing@SuperiorHealthPlan.com. 

If your address or telephone number changes, or if you can no longer accept new patients or are leaving the network, please notify Superior as soon as possible so we can update the Provider Directory. Having access to accurate provider information is vitally important to members, and Superior wants to work together to ensure continuity of care can be maintained.

Utilization Management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage.

Superior does not reward providers, practitioners, or other individuals for issuing denials of coverage or care and does not have financial incentives in place that encourage decisions resulting in underutilization. Denials are based on lack of medical necessity or lack of covered benefit. Nationally recognized criteria (such as InterQual or MCG) are used if available for the specific service request, with additional criteria (e.g., clinical/medical policies) developed internally through a process that includes a review of scientific evidence and input from relevant specialists.

Submitting complete clinical information with the initial request for a service or treatment will help Superior make appropriate and timely UM decisions. You may discuss any UM denial decisions with a physician or another appropriate reviewer at the time of notification of an adverse determination. You may also request UM criteria pertinent to a specific authorization request or for any other UM-related request or issue by contacting our Medical Management department at 1-877-398-9461.

Providers can contact our Medical Management department at 1-800-218-7508 to request a copy of the criteria used to make a specific decision. Providers can review utilization management clinical policies by visiting Superior’s Clinical, Payment & Pharmacy Policies. Utilization review decision making is based on appropriateness of care and service and the existence of coverage. Superior does not reward providers or other individuals for issuing medically necessary denials. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

Providing quality care to members includes helping adolescents transition to an adult care provider. If you or one of your patients need assistance in finding an adult primary care provider or specialist, or arranging care (if needed), contact Superior or reference the information in the Superior’s Provider Manuals.

Superior provides behavioral health services to members who need treatment for mental or emotional disorders and substance use disorders. Superior's fully integrated approach to managing behavioral and physical health services provides several benefits for our members and providers. Learn more about how Superior has focused on streamlining behavioral health processes and improving the provider's experience on Superior's Behavioral Health webpage. 

The health plan formulary/Preferred Drug List (PDL) is based on the benefits of the plan and is updated on a regular basis. The current PDL, which includes information regarding covered drugs, restrictions, prior authorization requirements, limitations, etc., can be accessed by visiting Superior's Pharmacy webpage.

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to:

• Address historical and contemporary injustices.
• Overcome economic, social, and other obstacles to health and healthcare.
• Eliminate preventable health disparities.

To achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. For more information about Culturally and Linguistically Appropriate Services (CLAS) standards, please reference https://thinkculturalhealth.hhs.gov/clas.

Together, Superior and providers must make language assistance services available to people with Limited English Proficiency (LEP) at all points of contact, during all hours of operation, and at no cost to our members. Superior can provide language assistance to members and providers without unreasonable delay at all vital points of contact. Providers can schedule language services, including telephone and face-to-face interpretation for non-English languages and American Sign Language, by calling our Member Services or by calling the toll-free number on the back of the member ID card. Additional resources can be found on Superior’s Language Assistance webpage.

Superior encourages providers to engage in Cultural Humility training and education to promote positive interaction with diverse cultures. To register for an upcoming training, visit Superior’s Provider Training Calendar. For more information about the Cultural and Linguistic Competency resources from the Office of Minority Health (OMH), see the Think Cultural Health Communication Guide. This program is designed to build knowledge, skills, and awareness of cultural and linguistic competency and CLAS to improve quality of care.

Our Care Management team is available for members who may benefit from increased coordination of services. The team supports providers with member issues including non-adherence to medications/medical advice, multiple complex co-morbidities, or to offer guidance with a new diagnosis.

Care Management helps members:

• Achieve optimum health, functional capability, and quality of life through improved management of their disease or condition.
• Determine and access available benefits and resources.
• Develop goals and coordinate with family, providers, and community organizations to achieve these goals.
• Facilitate timely receipt of appropriate services in the right setting.

Early intervention is essential to maximizing treatment options and minimizing potential complications associated with illnesses, injury, or chronic conditions. Members can receive services through face-to-face visits, over the phone, or in a provider's office. Providers can directly refer members to the Care Management program by initiating a referral on Superior’s Secure Provider Portal or by contacting a Superior Care Manager. For more information, please visit Superior’s Care Management webpage.

Every year Superior assesses appointment accessibility with PCPs, specialists, and behavioral health practitioners. There are established standards for each type of appointment (routine care, urgent/sick visits, etc.) and type of practitioner. Please review Superior’s Provider Manuals for the expectations of how quickly our members should be able to get an appointment.

Providers are expected to follow member rights. Members are informed of their rights and responsibilities in their member handbook.

Member rights include, but are not limited to:

• Receiving all services the health plan provides.
• Being treated with dignity and respect.
• Knowing their medical records will be kept private, consistent with state and federal laws and health plan policies.
• Being able to see their medical records.
• Being able to receive information in a different format in compliance with the Americans with Disabilities Act.
• Access to language services at all points of contact during all hours of operation and at no cost to the member.

Member responsibilities include:

• Understanding their health problems and telling their healthcare providers if they do not understand their treatment plan or what is expected of them.
• Keeping scheduled appointments and calling the physician's office whenever possible if there is a delay or cancellation.
• Showing their member ID card at appointments.
• Following the treatment plans and instructions for care that they have agreed on with their healthcare practitioner.

We encourage you to reference Superior’s Provider Manuals to review the full list of rights and responsibilities.

Superior HealthPlan is pleased to introduce the Choosing Wisely initiative. The American Board of Internal Medicine (ABIM) Foundation encourages practitioners and patients to "Choose Wisely". This initiative seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures.

Please visit choosingwisely.org to download informational resources for your patients and clinicians to promote shared-decision making.