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:
Members can appeal a medical decision within 60 calendar days of receiving our letter denying the initial request for services or payment on their own behalf. They can also designate a authorized representative including a relative, friend, advocate, doctor or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member's behalf.
If you are asking for a Standard Appeal or a Fast Appeal, make your appeal in writing, by fax 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
OR
FAX to: 1-844-273-2671
You may also ask for an appeal by calling us at 1-866-896-1844 (TTY: 711) 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 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 (PDF). 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 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 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
- We may extend the timeframe by up to 14 calendar days if you request an extension, or if we justify the need for additional information and the extension is in your best interest. If we take an extension, we will call you and send a letter to let you know.
- Please include copies of any additional information that may be important to your Appeal, and mail/fax that information to the following address/fax number below. The timeframe to submit additional information for an expedited appeal is limited due to the short timeframe to process your 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.
Requests for a State Fair Hearing are filed with Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP). However, State Fair Hearings are conducted by the Texas Health and Human Services Commission (HHSC) Appeals Division.
How to Request a State Fair Hearing:
Step 1: You or your representative must ask for a Fair Hearing (in writing) within 120 days of the date of the notice telling you that we are denying your Level 1 Appeal to our plan. The HHSC Appeals Division can extend this deadline if you have a good reason for being late.
If we’re stopping or reducing a service, you can keep getting the service while your case is being reviewed. To qualify, you must ask for a Fair Hearing within 10 business days of the date of the notice telling you that we are denying your Level 1 Appeal to our plan or before the service is stopped or reduced, whichever is later.
Your written request must include:
- Your name
- Address
- Member number
- Reasons for appealing
- Any evidence you want the HHSC Appeals Division to review, such as medical records, doctors’ letters or other information that explains why you need the item or service. Call your doctor if you need this information.
Step 2: Send your request to:
Superior STAR+PLUS MMP
Attn: Appeals & Grievances
5900 E. Ben White Blvd.
Austin, TX 78741
For more information, call Member Services at 1-866-896-1844 (TTY: 711). 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.
What is a Grievance?
A grievance is a complaint you or your appointed representative make about Superior STAR+PLUS MMP or one of our network providers or pharmacies. A grievance is a complaint about anything other than benefits, coverage or payment. You would file a grievance if you had problems with the quality or 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.
There are two types of Grievances (complaints)
- Internal Complaint – An internal complaint filed with and reviewed by our plan.
- External Complaint – An external complaint 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 complaint about your Medicaid services:
From the Texas Health and Human Services Commission:
Unhappy with your health plan or Medicaid services? Let us know. You can submit a complaint to tell us what’s wrong. Here’s how:
Step 1: Call your health plan.
Your health plan’s phone number is on your health plan ID card. Or, if you don’t have a health plan, call the Medicaid helpline at 1-800-335-8957(TTY: 711).
Step 2: If you still need help...
Call the Office of the Ombudsman at 1-877-787-8999 (TTY: 711) Monday through Friday, 8 a.m. –5 p.m. Central Time. Or, fill out this form: Ombudsman Complaint Process. The Office of the Ombudsman can help fix problems with your Medicaid coverage. If it’s urgent, the team will handle your complaint as soon as possible.
What to Expect:
- Call you back within one business day.
- Start working on your complaint.
- Check in with you once every five business days until it’s resolved.
- Tell you what happened and anything you might need to do.
When you call, you’ll need:
- Your Medicaid ID card number.
- Your name, birthday and address.
If it’s a problem with your doctor, your medication or the medical equipment you use, you might need:
- A phone number for your doctor, drugstore or medical equipment company
- Paperwork related to your complaint like letters, bills or prescriptions
Visit our website: Medicaid and CHIP – Contact Us
For CHIP health plan complaints email ConsumerProtection@tdi.texas.gov.
