Providing Quality Care
As a valued provider, your ability to serve Superior members is important. Superior has gathered helpful information to support you in delivering the very best care. This information is part of Superior's Quality Improvement (QI) program, designed to address both the quality and safety of services provided to your patients and Superior's members. Learn more about Superior's Quality Improvement Program by reviewing the information below and/or contacting your Account Manager.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a chance for your patients to report their satisfaction with their healthcare, including their experience with their providers and Superior. The CAHPS survey scores are available to the public and can determine whether patients and members stay with their provider or health plan, or look elsewhere for their care. Surveys are distributed to Superior members from February through June.
To learn more, please reference Superior's CAHPS Resource Guide.
You are essential to providing the highest-quality healthcare possible for Superior members, and your satisfaction is important to us, too. We assess your experience with Superior through an annual Provider Satisfaction Survey. These survey results are reviewed by Superior and will be key to helping us improve the provider experience. Please be sure to complete the survey if you receive one. Surveys are distributed to Superior providers from September through November.
The Qualified Health Plan Enrollee Experience Survey (QHP EES) is an opportunity for your patients to share their healthcare experiences with you as their provider and with their health plan. Your patients are asked specific questions, which include how well their doctor communicates, if they felt their doctor listened to them, and if their doctor explained things in a way that was easy to understand. Also included are questions on how well different healthcare providers are communicating about care coordination and a (0-10) rating of the patient’s overall satisfaction with their healthcare, personal doctor and specialists.
During the credentialing process, Superior HealthPlan obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key. You have the right to review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application 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 HealthPlan as soon as possible. We continually update our Provider Directory. Having access to accurate provider information is vitally important to our members, and we want 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 a 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 us 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 Superior's UM department. To request UM criteria or to discuss a denial please contact Superior’s UM Department at 1-877-398-9461 (Monday to Friday 8:00 a.m. to 5:00 p.m. local time).
Providing quality care to Superior members includes helping adolescents transition to an adult care provider, and when covered benefits are exhausted while a member continues to need care. If you or one of your patients need assistance in finding an adult Primary Care Provider (PCP) or specialist, or information about alternatives or resources for continuing care, contact Superior HealthPlan or reference the information in Superior's Provider Manuals. We can assist in locating an in-network adult care provider or arranging care, if needed.
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 Medicaid formulary includes a Preferred Drug List (PDL), which is based on the plan benefits and updated on a regular basis. The current PDL, which includes information regarding covered drugs, restrictions, prior authorization requirements, limitations, etc., is located on Superior's Pharmacy webpage. Providers can find a link to the Ambetter Formulary on Ambetters' Pharmacy Resources webpage.
Superior's Care Management team is available for members who may benefit from increased coordination of services. The team is available to assist and support providers with member issues including non-adherence to medications/medical advice, multiple complex co-morbidities, or to offer guidance with a new diagnosis.
The care management team 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. You can directly refer members to the Care Management program at any time by calling Superior at 1-855-757-6567 or initiating a referral on Superior's Secure Provider Portal.
Every year Superior assesses appointment availability for PCPs, specialists and behavioral health providers. There are established standards for each type of provider and appointment (routine care, urgent/sick visits, etc.). Please review Superior's Provider Manuals for the expectations on how quickly our members should be able to obtain an appointment.
To ensure a positive member experience, Superior encourages providers to participate in helping members understand their rights and responsibilities. Member rights and responsibilities help bridge the gap between the provider's responsibility to deliver quality care, and the member's understanding of their choices when seeking care. Providers can access a full list of Member Rights and Responsibilities, as well as view Provider Rights and Responsibilities in Superior's Provider Manuals.
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.