How Do I Ask For An Internal Health Plan Emergency Appeal Does My Request Have To Be In Writing
You, your provider, or your legal authorized representative can ask for an emergency appeal by calling Superiors Medical Management department at 1-877-398-9461. You can also ask for an emergency appeal in writing and send it to Superiors Medical Management department at:
Superior HealthPlan5900 E. Ben White Blvd.Austin, Texas 78741
FAX: 1-866-918-2266
Emergency appeals do not have to be in writing.
If you are eligible for both Medicare and Medicaid and need to request an emergency appeal for Medicare acute care services, please follow the expedited review process for your Medicare Plan/Program.
Medicaid Services For Children In State Foster Care
Most children in the State of Texas foster care are automatically eligible for Medicaid. To ensure these children have access to the necessary health care for which they are eligible, providers can accept the Your Texas Benefits Medicaid card, or the H1027 temporary eligibility form, as evidence of Medicaid eligibility. STAR Health, administered by Superior Health Plan, is the managed care program for children in State of Texas foster care. Below is an example image of the new card.
The Health Passport is an essential element of the program. It is a web-based repository of claims-based medical information on each child that improves information sharing and medical services coordination among the childs health-care providers, Department of Family and Protective Services staff, and caregivers. The Health Passport allows immediate access to a childs basic medical information so care can be continuous rather than disrupted if a child moves to a new placement or location. Visit Superior HealthPlan Network to learn more information.
What Are The Timeframes For This Process
The MAXIMUS Federal Services examiner will contact Superior immediately when they receive the request for External Review. Within five Business Days, Superior will give the examiner all documents and information used to make the internal appeal decision.
For standard External Review request:
You or someone acting for you will receive written notice of the final External Review decision as soon as possible. You will receive notice no later than 45 days after the examiner receives the request for an External Review.
For expedited or fast External Review request:
The MAXIMUS examiner will give Superior and you or the person filing on your behalf the External Review decision as quickly as medical status requires. You will get a decision no later than 72 hours of us receiving the request. You or someone acting for you will receive the decision by phone. MAXIMUS will also send a written version of the decision within 48 hours of the phone call.
Recommended Reading: Phone Number For Kentucky Medicaid
Ama Disclaimer Of Warranties And Liabilities
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
Who Can Be In Star+plus
To get services through STAR+PLUS you must: be approved for Medicaid, be one or more of the following:
- Age 21 or older, getting Supplemental Security Income benefits, and able to get Medicaid due to low income.
- Not getting SSI and able to get STAR+PLUS Home and Community-Based Services.
- Age 21 or older, getting Medicaid through what are called “Social Security Exclusion programs” and meet program rules for income and asset levels.
- Age 21 or over residing in a nursing home and receiving Medicaid while in the nursing home.
- In the Medicaid for Breast and Cervical Cancer program.
The following people can’t be in the STAR+PLUS program:
- People over 21 who get Medicaid 1915 waiver services or who live in community homes for people with Intellectual Developmental Disabilities , and get Medicare.
- People who are not able to get full Medicaid benefits, such as Frail Elderly program members, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualified Disabled Working Individuals and illegal immigrants.
- People who aren’t able to get Medicaid.
- Children in state foster care.
- Age 20 or younger and not in the Medicaid for Breast and Cervical Cancer program.
Important notes for those covered by Medicare:
You May Like: Can I See A Dentist With Medicaid
Unitedhealthcare Connected General Benefit Disclaimer
This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.
You can get this document for free in other formats, such as large print, braille, or audio. Call Member Services, 8 a.m. – 8 p.m., local time, Monday – Friday . The call is free.
You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future.
Language Line is available for all in-network providers.
Puede obtener este documento de forma gratuita en otros formatos, como letra de imprenta grande, braille o audio. Llame al Servicios para los miembros, de 08:00 a. m. a 08:00 p. m., hora local, de lunes a viernes correo de voz disponible las 24 horas del día,/los 7 días de la semana). La llamada es gratuita.
Puede llamar a Servicios para Miembros y pedirnos que registremos en nuestro sistema que le gustaría recibir documentos en español, en letra de imprenta grande, braille o audio, ahora y en el futuro.
What Are The Timeframes For The Internal Health Plan Appeals Process
Medicaid members will have sixty calendar days from the date of Superiors Notice of Adverse Benefit Determination letter to appeal the decision. Superior will acknowledge your appeal within five business days of receipt, complete the review of the appeal, and send you an appeal response letter within thirty calendar days after receipt of the initial written or oral request for appeal.
An additional 14 days may be added to process the appeal, if you request an extension or Superior shows that there is a need for additional information and how the delay is in the members interest. If more time is needed to gather facts about the requested service, you will receive a letter with the reason for the delay. If you do not agree with Superiors decision to extend the timeframe for the decision on your appeal, you can file a complaint.
Recommended Reading: Doctors Who Accept Medicaid For Tummy Tucks
How To Choose A Health Plan
When picking a plan, think about the following:
- Are doctors you already use and like covered by the plan?
- How is the plan rated on issues that are important to you and your family?
- What value-added services are available through the plan?
We also provide tools to help you choose the best plan for you and your family.
What Is An External Review
An External Review is an outside review of your health plans denial of a service you and your doctor feel is medically necessary. The External Review process is managed by MAXIMUS Federal Services for CHIP members. This organization is not related to your doctor or to Superior. There is no cost to you for an External Review. You can ask for an External Review after you complete the appeal process with Superior, or if Superior has denied a service that you think is life threatening.
You May Like: Should I Apply For Medicaid Or Obamacare
Health Plan Report Cards
People across Texas shared their thoughts about their health plan, and rated them, one to five stars, on the services their plan provided. You can compare plans using the overall ratings or by looking at the services that matter the most for you and your family.
You can view the report cards on the Managed Care Report Cards page. Click the program you are enrolled in and find your service area to see plans available to you.
Star+plus Expansion Consumer Outreach Forums
To: DADS Providers Identified in Information Letter 11-119, Affected by the March 1, 2012 STAR+PLUS Expansion into the Lubbock, El Paso and Hidalgo Service Areas
This alert provides a link to the current Medicaid event calendar for consumer outreach events. These outreach events are held for consumers affected by the March 1, 2012 STAR+PLUS expansion into the Lubbock, El Paso and Hidalgo service areas. Outreach events provide opportunities for the enrollment broker, MAXIMUS, to educate individuals who will be enrolled in STAR+PLUS, and their families, about the services and benefits available through the various managed care organizations.
Following is the link to the Community Outreach Meeting calendar:
The calendar of events is updated regularly. Consumers can select any event they want to attend by following the instructions provided on the events link.
Consumers should have received a STAR+PLUS introductory letter in the mail. Consumers should also have received their STAR+PLUS enrollment packet by the end of December, 2011. If they do not receive either document, please have them call 1-800-964-2777 . Following is the link for the Lubbock and El Paso service areas for the community outreach calendar, consumer introduction letters, and frequently asked questions : .
The hosting LTSS provider/organization will need to provide the following information:
You May Like: Neurologist In Alexandria La That Accept Medicaid
Star Kids And Star+plus Members
All STAR Kids members get connected with a service coordinator through their health plan. STAR+PLUS members with complex medical conditions also get a service coordinator through their health plan.
Service coordination can help ensure you get the services you need. Service coordinators are provided by your health plan to help manage your health care and long-term care needs, which can include access to community resources and help with food and housing. They work with you, your primary care provider, and your specialty and non-medical providers to develop and carry out an Individualized Service Plan.
A Proven Solution For State Health Programs
With our person-centric approach, we streamline the decision making and enrollment processes for beneficiaries, and proactively engage them at critical points to ensure they enroll and re-enroll as necessary. Our Eligibility and Enrollment solution:
- Offers a straightforward application that seamlessly works across multiple health insurance programs
- Reduces the documentation required to determine program eligibility
- Provides multichannel access via mail, fax, web and phone
- Gives consumers self-service tools with 24/7 access
- Promotes application completion through plain language educational materials, applications, forms, instructions and websites
- Addresses diverse language and literacy levels with multilingual materials and customer service representatives
Read Also: Colorado Dentists That Accept Medicaid
How To Submit A Complaint
Unhappy with your health plan or Medicaid services? Let us know. You can submit a complaint to tell us whats wrong. Heres how:
Step 1: Call your health plan.
Your health plans phone number is on your health plan ID card. Or, if you dont have a health plan, call the Medicaid helpline at 1-800-335-8957.
Step 2: If you still need help
Call the Office of the Ombudsman at 1-866-566-8989 Monday through Friday, 8 a.m. 5 p.m. Central Time. Or, fill out the Complaint Submission form. The Office of the Ombudsman can help fix problems with your Medicaid coverage. If its urgent, the team will handle your complaint as soon as possible.
What to Expect
- Start working on your complaint.
- Check in with you once every five business days until its resolved.
- Tell you what happened and anything you might need to do.
When you call, youll need:
- Your Medicaid ID card number
- Your name, birthday and address
If its 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
For CHIP health plan complaints email .
What Kind Of Appeal Should You File
- Standard Appeal: An appeal that does not involve urgent care such as emergency care, life threatening conditions, or continued hospitalization.
- Expedited Appeal: An expedited appeal is available for denial of emergency care, a denial of continued hospitalization, or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient.
- Specialty Appeal: The provider of record may request a specialty review the case within 10 working days from the date the appeal was requested or denied.
- Acquired Brain Injury Appeal: An appeal of denied services concerning an acquired brain injury.
Don’t Miss: Can You Get Medicaid With Medicare
The Power Of Partnership
Maximus and our partners provide state-of-the-art technologies to deliver omnichannel engagement, conversational AI, and insights and data to deliver an optimal customer experience.
Genesys
Genesys is a leading provider of omnichannel engagement platforms automating citizen engagement, digital experiences, and contact center operations. Our partnership with Genesys includes the Genesys Cloud platform and our FedRAMP Maximus Genesys Engagement Platform.
Interactions
Interactions provides Intelligent Virtual Agents that seamlessly assimilate Conversational AI and human understanding to enable businesses to engage with their customers in highly productive and satisfying conversations. With flexible products and solutions designed to meet the growing demand for unified, opti-channel customer care, Interactions is delivering unprecedented improvements in the customer experience.
Success KPI
SuccessKPI is purpose-built to drive Federal Cloud Contact Center Modernization through a revolutionary Insight & Action Platform that mitigates compliance risk while ensuring a great experience for citizens & government employees.
When Do I Have The Right To Ask For An Appeal
You have the right to appeal Superiors decision if CHIP covered services are denied based on lack of medical need. Superiors denial is called an adverse benefit determination. You can appeal the adverse benefit determination if you think Superior:
- Is stopping coverage for care you think you/your child needs.
- Is denying coverage for care you think should be covered.
- Provides a partial approval of a request for a covered service.
You, a doctor or someone else acting on your/your childs behalf can appeal an adverse benefit determination.
Recommended Reading: Does Medicaid Cover Couples Therapy
Star Medicaid Managed Care Program
Most people who have Medicaid in Texas get their coverage through the STAR managed care program. STAR covers low-income children, pregnant women and families. STAR members get their services through health plans they choose.
If you’re new to STAR, you’ll choose a health plan from the ones available in your service area . Learn more about how to choose or change your health plan.
Can Someone From Superior Help Me File An Appeal
You, your provider or another person acting on your behalf can file an appeal. A Superior Member Advocate can help you with any questions you have about filing an appeal. You can call Member Services at 1-800- 783-5386 with any questions. Interpreter services are provided free of charge, call Member Services for assistance.
Recommended Reading: Does Medicaid Cover Tonsil Removal
How To File An Appeal
To request a health plan appeal you can:
- File a written appeal using the Health Plan Appeal Request Form. Mail or fax it to us using the address or fax number listed at the top of the form.
- File an oral appeal by calling the BCBSTX Customer Advocate Department toll-free at , Monday through Friday, 8 a.m. to 5 p.m., Central Time.
- Dallas, TX 75266-0717
- Call a Member Advocate for help filing an appeal at
You must request an appeal by 60 days from the date your notice for denial of services was mailed. We will give you a decision on your appeal within 30 days.
Maximus Contact Centers In Georgia Indiana New York And Texas Recognized As Center Of Excellence By Benchmarkportal
RESTON, Va.—-MAXIMUS , a leading provider of government services worldwide, announced today that its customer contact center operations in Georgia, Indiana, New York and Texas have achieved Center of Excellence re-certification by BenchmarkPortal. These contact centers provide support for the Georgia Childcare and Parent Services , Georgia Families, Indiana Enrollment Broker Services , New York Medicaid CHOICE , and Texas Eligibility Support Services and the Texas Enrollment Broker operations.
“The BenchmarkPortal distinction underscores our firm commitment to delivering high quality services to citizens in the most efficient way, said Bruce Caswell, President and Chief Executive Officer of MAXIMUS. This recognition is well deserved by our dedicated teams in all five projects for helping ensure accessibility to health and child care services for families and children in their state.
The BenchmarkPortal Center of Excellence distinction is based on best practice metrics drawn from the worlds largest database of objective and quantitative performance data from thousands of contact centers. Performance data collected from the MAXIMUS contact centers achieved BenchmarkPortals rigorous standards of efficiency and effectiveness in areas such as operational efficiency, service level standards, customer satisfaction and employee training.
About MAXIMUS
About BenchmarkPortal
Don’t Miss: Doctors That Take Medicaid In Baton Rouge
How Can I Ask For A State Fair Hearing
You must complete the internal health plan appeal process through Superior HealthPlan prior to requesting a State Fair Hearing. If you disagree with Superiors appeal decision, you have the right to ask for a Medicaid State Fair Hearing from Texas Health and Human Services with or without an External Medical Review through an Independent Review Organization . You can ask for an External Medical Review and a State Fair Hearing, but you cannot request only an External Medical Review. You may also request a State Fair Hearing with or without an External Medical Review if Superior does not make a decision on your appeal within the required time frame. You may represent yourself at the State Fair Hearing, or name someone else to be your representative. This could be a doctor, relative, friend, lawyer, or any other person. You may name someone to represent you by writing a letter to Superior telling them the name of the person that you want to represent you.
You or your representative must ask for a State Fair Hearing within 120 days of the date of the notice telling you that we are denying your appeal with Superior.
If Superior continues or reinstates benefits at your request and the request for continued services is not approved by the State Fair Hearing officer, Superior will not pursue recovery of payment for those services without written permission from HHS.
