Out of Network Coverage (Part C)
Most of the time, you must get your health care from a Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) contracted provider. Usually the plan will not cover health care services from a provider who does not work with the health plan. However, there are some situations in which this rule does not apply:
- If you have an emergency or need urgent care and an in-network provider is not nearby.
- If you need care than the plan covers and our network providers cannot give it to you, you may get that care from an out-of-network provider. A prior authorization will be required first.
- If you need kidney dialysis services when you are outside the plan’s service area for a short time, you can get these services at a Medicare-certified dialysis facility
- When you first join the plan, you can continue to see the providers you see now for at least 90 days. If you need to continue to see your provider after your first 90 days in our plan, your care will only be covered if your provider enters into a single case agreement with us. Contact your service coordinator for more information at 1-855-772-7075 (TTY:711).
- Your primary care provider or Superior STAR+PLUS MMP will most likely need to approve the service you are seeking. Without approval, you will have to pay for the service.
For more information, please refer to your Member Handbook or 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.
Out-of- Network Coverage
Most of the time, you must get care from a Superior HealthPlan provider. There are some times when network providers may not be close to your area. Those times are:
- In an emergency
- When urgent care is needed that you cannot get from network provider
- When care is needed that cannot be offered by a network provider
- Continuity of care.
- Kidney dialysis services when you are outside the plan’s service area
Your primary care provider or Superior HealthPlan needs to approve the service. Without an approval, you will have to pay for the service.
In some cases your doctor may send you to an out-of-nework doctor. Your doctor will need to get prior approval from the health plan.
Some of these reasons may be because:
- Services are not available in network as soon as you need them
- Your doctor decides that an out-of-network doctor would be better for the member.
See your Member Handbook for more information.
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.
Last Updated: 09/30/2017