Tag: Superior
Change HealthCare!
Looking for answers? So is POET. We are looking for work-arounds. Hopefully we will have some up before closing today.
Updated Clinical Prior Authorization
Assistance Chart Now Available
An update to the Clinical Prior Authorization Assistance Chart is available. The chart identifies which clinical prior authorization each MCO uses and whether the MCO uses all or some of the steps in the evaluation process.
Superior: Avoid Claim Denials
BILLING: Avoid Claim Denials
As a reminder, claims submitted with invalid or unclean data will result in denial or rejection of an entire claim. Superior has provided a list of important claim submission tips and common billing errors to help ensure your claims are processed quickly and efficiently.
Review the full list of tips to ensure your claims are not denied. Just click the link.
Superior Pediatric Vaccines 11/1/2023
For questions, please contact Pharmacy Provider Services
Updated: Vaccine Information
Date: 11/01/23
The best way to stay protected against COVID-19 and flu is by staying updated on vaccines. Superior HealthPlan would like to inform providers about current COVID-19 and flu vaccine coverage.
COVID-19 Vaccines
The United States Food and Drug Administration (FDA) approved updated versions (2023-2024 formulation) of the COVID-19 vaccines; both the Pfizer and Moderna versions were approved in September and the Novavax version was approved in early October.
The Vendor Drug Program (VDP) is still working on getting the new COVID-19 vaccines added to the pharmacy formulary with no provided ETA. Superior Medicaid and CHIP members can obtain the new COVID-19 vaccines through their medical provider in the meantime or wait and return to the pharmacy once the VDP and the Texas Health and Human Services Commission have added the new vaccines to the pharmacy benefit. Please check the VDP Product Search for the most updated coverage of vaccines.
Flu Vaccines
The 2023-2024 flu vaccine formulations were added by the VDP to the pharmacy benefit on September 1, 2023. Similar to last year’s flu season, Medicaid and CHIP members who are 3 years of age and older can obtain their flu vaccine from a participating pharmacy. All members under 3 years of age will need to obtain a flu vaccine from their medical provider.
Superior Prior Auth Changes Eff. 1/1/2024
For some services, utilization review is necessary to determine the medical necessity and appropriateness of a covered health care service for Superior HealthPlan’s managed care members. For those services, utilization review is performed BEFORE (prior authorization), during (concurrent review) or after (retrospective review) the service is delivered.
10,000 Members Lost Medicaid Coverage
HHSC Notice: Erroneous Termination of Superior Member Coverage
A recent notice from the Texas Health and Human Services Commission (HHSC) indicated that approximately 10,000 Superior HealthPlan members incorrectly lost their Medicaid coverage after April 1, 2023. This error is currently being addressed by HHSC, and we anticipate the reinstatement of benefits for these members soon.
Requested Action for Providers
Member Reimbursements
- Should members approach you with a request for refunds due to out-of-pocket expenses made during their period of interrupted coverage, they are entitled to full reimbursement.
- It is essential that you promptly process these refunds.
- As indicated by HHSC, these members will continue to have coverage until their cases have been reviewed. Any services for these members provided during this period can be billed to Superior HealthPlan.
Prompt Claim Submission
- After processing member refunds, please submit the relevant claims to Superior immediately. This swift action is crucial to avoid denials due to timely filing.
Prompt Claim Re-Submission
- If a claim was rejected as a result of member ineligibility, please resubmit the claim for processing.
- If a denial was received and is within 95 Days of the denial date, please submit a new claim.
- If more than 95 Days have elapsed since the denial, please follow the process for submitting a reconsideration, outlined in the Claims Reconsiderations section of the Superior HealthPlan STAR, CHIP, STAR+PLUS, STAR Health and STAR Kids Provider Manual. In the reconsideration request, please indicate: Member’s eligibility retroactively reinstated.
Handling Timely Filing Denials
- If you face a denial for timely filing, please follow the process for submitting a reconsideration, outlined in the Claims Reconsiderations section of the Superior HealthPlan STAR, CHIP, STAR+PLUS, STAR Health and STAR Kids Provider Manual. In the reconsideration request, please indicate: Member’s eligibility retroactively reinstated. Please also include the following when submitting a reconsideration:
- Explanation of payment.
- Documentation showing the reimbursement provided to the member for the affected dates of service.
For additional support, queries or clarifications regarding this situation, please contact your local Account Manager.
Superior Risk Adjustment Training
Superior will be hosting a series of webinars to assist providers with Risk Adjustment Documentation and Coding. All levels of clinicians and billing and coding staff are encouraged to attend.
LexisNexis – Superior
If you receive a letter from LexisNexis requesting directory information for Superior, and you have opt’ed into POETs Superior Agreement, you do not need to fill this out. Please notify POET.
However, anytime you have demographic changes in your practice, POET needs to know as soon as possible. It is POET’s responsibility to provide that information to the insurance plans, you have opt’ed into with us. This includes but is not limited to:
- Adding Provider to Practice
- Address
- Phone Number
- Billing Address
- Changes Concerning AHP
- Office Manager Changes
- Provider Leaving Practice
- Practice Name Change
- Office Manager Changes
- TIN or NPI Changes
Superior Prior Auth Requirements
Superior will be ending any active prior authorizations for Synagis® effective February 1, 2022 for all Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members to align with HHS guidance. As the season has ended, claims for Synagis® will no longer adjudicate pursuant to the end of the season per VDP guidance.
Superior HealthPlan will require prior authorization for CPT code 81519, Oncology Breast MRNA, for Medicaid, CHIP and Superior HealthPlan Medicare-Medicaid Plan (MMP) members. Superior HealthPlan will utilize Change Healthcare’s InterQual as the medical necessity review criteria. Effective on May 1, 2022
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