Skip to Main Content

Prior Authorization (Part C)

What is Prior Authorization?

Prior authorization means that you must get approval from Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) before you can get a specific service or drug or see an out-of-network provider. Superior STAR+PLUS MMP may not cover the service or drug if you don’t get approval. If you need urgent or emergency care or out-of-area dialysis services, you don't need to get approval first.

Which services require Prior Authorization?

To get a list of services that require prior authorization, please refer to your Member Handbook or contact Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711).

What is the process for getting Prior Authorization?

Either you or your doctor may request a prior authorization.  Members should call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711). Providers may submit a prior authorization by phone, fax or web.

If your doctor wants you to get services quickly, we will notify you if the service is approved within 1 (one) business day after we get your request.  If we find that your health may be in danger we will hurry your request.

For all other requests, you will receive a response within 3 (three) business days.

We will tell you our decision either in writing or by telephone. Please note that in the case of an emergency, you do NOT need Prior Authorization.

Prior authorization approval is not a guarantee of payment. Superior STAR+PLUS MMP has the right to review all services for medical need after you receive the services. You must be eligible for the services you are requesting prior approval for. Some services have limits. Some benefits have exclusions.

If you have additional questions, please refer to your Member Handbook, or 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. 

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.

Appeal form

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

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). 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.

 

Last Updated: 04/19/2018
H6870_18_WebCAHPS_Approved_04192018