Complaint Procedures

Superior offers a number of ways to file a complaint, as listed below:

• Online through Superior’s Complaint Form.
• Faxing or mailing a Complaint Form to Superior for a resolution response. 
• Mailing or faxing a written complaint to the following:

Superior HealthPlan
ATTN: Complaint Department
5900 E. Ben White Blvd.
Austin, Texas 78741
Fax: 1-866-683-5369

• Calling Provider Services at 1-877-391-5921

For help filing a provider complaint or to check on the status of a provider complaint, providers may email TexasProviderComplaints@centene.com.

When a complaint is received, a written acknowledgement letter is sent to the provider within five (5) business days of receipt of the complaint. Superior then has thirty (30) calendar days to resolve the complaint. The response to the complaint will be provided in writing in the form of a resolution letter. If the resolution/response is not satisfactory, a complaint appeal may be filed.

Superior maintains all documentation (fax, electronic and telephonic) related to the receipt and response to the complaint, to include routing and correspondence maintenance, within the current software solutions used for complaints processing. The system used accommodates a secure and complete record of each complaint and any complaint proceedings or actions taken on a complaint/complaint-appeal according to minimum record retention requirements.

Superior will maintain documentation on each complaint/appeal until five (5) years after the termination of the contract with the Health and Human Services Commission. Such documentation for each complaint/appeal filed includes date of receipt, identification of the individual filing the complaint/appeal, all documentation pertaining to the complaint/appeal, identification of the individual recording the complaint/appeal, the substance and nature of the complaint/appeal, investigation details and the disposition and resolution of the complaint/appeal and the date resolved.

Providers may file a complaint with HHSC after exhausting Superior’s complaint procedures by submitting to STAR.Health@hhsc.state.tx.us, or:

Texas Health and Human Services Commission
Health Plan Management – H-320
P.O. Box 85200
Austin, TX 78708-5200

It is important to note that inquiries or appeals related to claims are handled separately from provider complaints. Please review the Superior Provider Manual for the process for claims inquiries and appeals. Claim status can be viewed via the Superior web portal as well. For claims status inquiries or appeals, contact Superior’s Provider Services claims hotline at 1-877-391-5921.

The complaint process does not include medical necessity appeals that are directed to the plan’s Medical Management Department. Please refer the Superior Provider Manual for details related to medical necessity denials and appeal. Medical necessity appeals are submitted to Superior to:

Superior HealthPlan
Attention: Appeals/Denials Coordinator
5900 E. Ben White Blvd.
Austin, Texas 78741
PHONE: 1-877-398-9461
FAX: 1-866-918-2266

Please note: Appeals must be submitted to the Superior appeals mailing address, however participating or non-participating providers may use the appeals email address to file or check the status of a pre-service appeal for any product line at MMPAppeals_Grievances@centene.com.

Providers may appeal claim recoupment by submitting the following information to HHSC:

• A letter indicating that the appeal is related to a managed care disenrollment or retro-eligibility recoupment and that the provider is requesting an Exception Request.
• The Explanation of Benefits (EOB) showing the original payment. Note: This is also used when issuing the retro-authorization as HHSC will only authorize the Texas Medicaid and Healthcare Partnership (TMHP) to grant an authorization for the exact items that were approved by the plan.
• The EOB showing the recoupment and/or the plan’s “demand” letter for recoupment. If sending the demand letter, it must identify the client name, identification number, DOS and recoupment amount. The information should match the payment EOB.
• Completed clean claim. All paper claims must include both the valid NPI and TPI number. Note: In cases where issuance of a prior authorization (PA) is needed, the provider will be contacted with the authorization number and the provider will need to submit a corrected claim that contains the valid authorization number. Mail appeal requests to:

Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management, Mail Code-91X
P.O. Box 204077
Austin, Texas 78720-4077

An appeal is the request for review of a “Notice of Adverse Action.”  A “Notice of Adverse Action” is considered the denial or limited authorization of a requested service, including:

• The type or level of service;
• The reduction, suspension, or termination of a previously authorized service;
• The denial, in whole or part, of payment for a service excluding technical reasons;
• The failure to render a decision within the required timeframes; or
• The denial of a member’s request to exercise his/her right to obtain services outside the Superior network.  

The review may be requested orally or in writing; however, oral requests for appeals within the standard timeframe must be resolved within 30 days of receipt of the appeal, with a 14-day extension possible if additional information is required. Members may request that Superior review the “Notice of Adverse Action” to verify if the right decision has been made. Expedited appeals may be filed when either Superior or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or his/her ability to attain, maintain or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.

Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. For any extension not requested by the member/provider, Superior shall provide written notice to the member of the reason for the delay. Superior shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two  calendar days with a written notice of action.