Appeals and Grievances

What is an Appeal?

An appeal is the process to review a decision you may not like. The negative decision is called a Coverage Determination. If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. If you had to pay for a service and want to be paid back, you can ask us. If your appeal is to pay you back, we will tell you in writing within 60 days. A Coverage Determination can result in both a negative decision and a positive decision.

There are Two Kinds of Appeals:

Standard Appeal – If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. You will get a written answer on a Standard Appeal 30 days after we receive your appeal. We may take longer if you ask for more time, or if we need to know more about your case. We will tell you if we are taking extra time and will explain why more time is needed. 

Fast Appeal – You can ask for a Fast Appeal if you or your doctor think your health could be in danger. You will get an answer within 72 hours after we get your appeal.

If your doctor asks for a Fast Appeal, you will get one.

If you want a Fast Appeal but your doctor did not ask, we may not approve it. 

If we don’t give you a Fast Appeal, we’ll give you an answer in 30 days.

How to File an Appeal:

If you are asking for a standard appeal or a fast appeal, make your appeal in writing or call us.

You can submit a request to the following address:

Superior STAR+PLUS MMP
Attn: Appeals and Grievances – Medicare Operations
7700 Forsyth Blvd
Saint Louis MO 63105

You may also ask for an appeal by calling us at 1-866-896-1844 (TTY: 711) 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day.

If you want someone else to file your appeal on your behalf, provide us with an Appointment of Representative (AOR) Form (CMS-1696 Form). This is a legal form showing that you picked someone to file for you. This person has your permission to see all notes from your doctor about the appeal.

To find out how we work your appeal you can call us at 1-866-896-1844 (TTY: 711). To find out how we are doing with your appeal call the same number.

If your doctor needs to talk with us for the same thing, they can call 1-877-391-5921.

What Do We Do When You File an Appeal?

We will have a different doctor look at your case to see if we should change our mind. We may need more information from you or your doctor. We must make sure we have everything done on time. We will get your appeal done as fast as your health situation needs it, but no later than:

  • 30 days for a Standard Medical Appeal (Part C & Medicaid)
  • 72 hours for a Fast Medical Appeal (Part C & Medicaid)
  • 7 days for a Standard Prescription Drug (Part D) Appeal
  • 72 hours for a Fast Prescription Drug (Part D) Appeal

What Happens Next?  

If we do not approve your request with your appeal, we will send you a letter. For Medicare services appeals, we will also send your case to an independent reviewer. An independent reviewer is a third reviewer called the Medicare Independent Review Entity or IRE. The IRE will send you a letter with a decision and tell you if you have more options.

You May Also Have the Right to Request a State Fair Hearing:

If you do not agree with the appeal decision for Medicaid covered services, you can request a State Fair Hearing.

To ask for a State Fair Hearing you have to tell us. The notification can be from you, your representative or your doctor. You must ask us within 90 days from the date of the letter you got telling you that services were not covered.

Use the section above called ‘How to file an appeal’.

For more information, call Member Services at 1-866-896-1844 (TTY: 711). Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day.

What is a Grievance?

A grievance is a complaint you make about Superior STAR+PLUS MMP or one of our network providers or pharmacies.  This includes a complaint about the quality of your care.

There are two types of Grievances (complaints)

Internal Complaint – An internal complaint is filed with and reviewed by our plan.

External Complaint – An external complaint is filed with and reviewed by an organization that is not affiliated with our plan.

If you need assistance making an internal and/or external complaint, you can call the HHSC Ombudsman’s Office at 1-877-797-8999 (TTY: 711).

How to file a grievance (complaint)?

To make an internal complaint, call Member Services at 1-866-896-1844 (TTY: 711) 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. Complaints related to Part D must be made within 60 calendar days after you had the problem you want to complain about. If you are requesting action on any other Medicare or Texas Medicaid issue, the complaint must be made within 90 calendar days after you had the problem you want to complain about.

If there is anything else you need to do, Member Services will tell you.

You can also send your complaint in writing to:

Superior STAR+PLUS MMP
Superior STAR+PLUS MMP
Attn: Appeals and Grievances -- Medicare Operations
7700 Forsyth Blvd

St. Louis, MO 63105 We will answer your complaint within 30 calendar days. However, if we need to gather more information that may help you, we can take up to 14 more calendar days. If you believe we should not take extra days, you can file a “fast complaint.” You can also file a fast complaint if we deny your request for a “fast coverage decision” or a “fast appeal.” When you file a fast complaint, we will give you an answer to your complaint within 24 hours. Call Member Services to file a “fast complaint.”

To make an external complaint contact Medicare directly.  The Medicare Complaint Form is available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx or you can call 1-800-633-4227 (TTY: 1-877-486-2048).  The call is free.

For more information, please refer to your Member Handbook or call Member Services at 1-866-896-1844 (TTY: 711). Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day.

What is a Grievance?

A grievance is a complaint about anything other than benefits, coverage or payment. You would file a grievance if you had problems with the value of your medical care, waiting times or the customer service you receive. You would file a grievance if you did not think we responded fast enough to your request for coverage determination or organization determination, or to your appeal.

Filing a Grievance

You or your appointed representative can file a grievance by:

  • Sending your complaint in writing to the address below:

    Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP)
    Attn: Appeals and Grievances – Medicare Operations
    7700 Forsyth Blvd
    Saint Louis MO 63105
  • Calling our Superior STAR+PLUS MMP Member Services team at 1-866-896-1844 (TTY: 711)
  • Faxing your complaint to us at 1-844-273-2671
  • Calling Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048). Calls to this number are free 24 hours a day, 7 days a week.
  • By visiting www.Medicare.gov for more information, call Member Services at 1-866-896-1844. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned the next business day. TTY users call 711. 

Appeal form…Coming Soon
Complaint Form…Coming Soon

Last Updated: 10/01/2016
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