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Quick Guide to Superior's Medical Necessity Appeal Process

Date: 03/01/18

In an ongoing effort to provide quality care to members, Superior has medical necessity appeal procedures available to members when a covered service is denied for lack of medical necessity.

An appeal is the mechanism which allows members, and providers on behalf of a member, the right to appeal actions (for Medicaid) or adverse determinations (for CHIP, Ambetter) issued by Superior. Superior members have the right to appeal a utilization review decision when the member, or provider on behalf of the member, believes the requested services are medically necessary.

Providers have the option to request a peer-to-peer discussion at any time during the prior authorization, denial or appeal process. For STAR Health, Ambetter and CHIP adverse decisions, the opportunity for a peer-to-peer discussion is offered prior to issuing an adverse determination.

Appeals through Superior

Standard Appeals: A standard appeal does not involve urgent care such as emergency care, life-threatening conditions, or continued hospitalization.

  • Medicaid and CHIP medical necessity appeal requests must be received within 60 calendar days from the date of notification of the adverse determination.
  • Ambetter appeals must be received within 180 calendar days from the date of notification of the adverse determination.
  • Superior acknowledges a standard appeal request within five business days of receipt, and renders a decision within 30 calendar days.
  • Any additional information that may be used in consideration of the appeal must be submitted to Superior, within the requested timeframe.

Expedited Appeal: An expedited appeal is available for emergency care, life-threatening conditions, and hospitalized enrollees. An expedited appeal is also available for denials of prescription drugs and intravenous infusions for which the enrollee is currently receiving benefits, and a denied step therapy protocol exception request.

  • An expedited appeal will be resolved and verbal notification provided within one working day.
  • The notification letter for an expedited appeal will be provided within 3 business days from the date of the request.

Please note: For Medicare appeals processes, please reference the Allwell from Superior HealthPlan provider manual.

External Appeals

State Fair Hearing: A state fair hearing is available to Medicaid members after Superior’s internal appeal process is exhausted.

  • Members must request a state fair hearing within 120 days of Superior’s denial upon appeal.
  • Requests are submitted to Superior, who provides the case file for the state fair hearing to the state fair hearing office, and also participates in the state fair hearing.
  • The state fair hearing office makes the decision of the case.

Independent Review Organization (IRO): An IRO is available to CHIP and Ambetter members after Superior’s internal appeal process is exhausted.

  • The IRO will issue a determination on the case in 20 days, with notice to the member and Superior. If the member has a life-threatening condition or receives a denial for prescription drugs or intravenous infusions for which they are currently receiving benefits, the member, or someone acting on the patient’s behalf, and the provider of record can request an immediate review by an IRO and is not required to follow Superior’s internal appeal procedures.
  • Upon receipt of the request, the IRO will issue a determination for life threatening conditions, denials for prescription or intravenous infusions and step therapy denials within 3 days.

For more information, please review the Superior provider manuals found on the Training and Manuals webpage, or reach out to Provider Services at 1-877-391-5921 with any questions.