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 an affirmative 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:
To ask for an appeal you have to tell us. It can be from you, your representative or your doctor.
Step 2: You can write, mail or fax or deliver your appeal, or you can call us.
For a Standard Appeal:
Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP)
Attn: Appeals and Grievances
7700 Forsyth Blvd
Saint Louis MO 63105
Phone: 1-866-896-1844, TTY call 711
If you ask in writing, your appeal must include your:
- Member number.
- Reasons for the appeal.
- Medical records, notes or a letter from your doctor.
- Other information that shows why you need the item or service. Call your doctor if you need this information.
If you want someone else to file your appeal on your behalf, provide us with an Appointment of Representative Form (CMS-1696 Form).
This is a legal form showing that you picked someone to file for you. This person has your okay 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 or 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 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 we told you that it wasn’t covered.
Use the section above called ‘How to file an appeal’.
For more information, call Member Services at 1-866-896-1844. Hours are from 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.
Last Updated: 10/01/2016