Provider Reminders: Claims Definitions

Date: 05/21/20

As a reminder, providers should review the definitions for rejected (unclean) claims and timely claim filing below:

• Rejected Claim (Unclean Claim): An unclean claim that does not contain all elements necessary to process the claim, and/or is not the responsibility of Superior for adjudication. Claims can be rejected by the Superior’s clearinghouse, Electronic Data Interchange (EDI) process or claims process.
• Timely Claim Filing: The receipt of a clean claim must be within the timeframe applicable to the claim type. Superior must receive all:
  • Outpatient (office, facility, ancillary) provider claims within 95 days from each date of service on the claim.
  • Inpatient hospital claims (including all interim bills) within 95 days from the date of discharge.
  • Nursing facility claims within 365 days from the date of service on the claim. 

Please note: All rejected claims must be corrected and resubmitted within 95 days of the date of service, and therefore a previously rejected claim will not be honored to substantiate timely claim filing.

For questions on claim payments, rejections, denials, to verify eligibility or for help escalating any issues, please contact Provider Services at:

• 1-877-391-5921 for Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS) and CHIP, STAR+PLUS Medicare-Medicaid Plan (MMP) and Allwell from Superior HealthPlan (HMO and HMO SNP)
• 1-877-687-1196 for Ambetter from Superior HealthPlan

For claims related questions, be sure to have your claim number available, and contact your local Account Manager.

Please be advised that validation of any and all HIPAA information will occur.

For additional information regarding rejected claims and timely filing requirements and contact information, you may refer to the Superior’s Provider Manuals located on Superior’s Provider Training and Manuals webpage.