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 Operatons
7700 Forsyth Blvd
Saint Louis MO 63105
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). 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
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 Fair Hearing are filed with Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP). However, 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 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
- 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 HealthPlan 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 grievance (complaint)?
To make an internal complaint, call Member Services 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.
You can also fax your complaint to us at 1-844-273-2671.
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
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-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048 24 hours a day, 7 days a week. 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 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.