Tag: Superior
Co-pays Resuming for Certain Services
Effective 10/1/24: Co-pays will Resume for CHIP CoVid19 Services.
During the COVID-19 public health emergency, the Texas Health and Human Services Commission (HHSC) waived co-pays for COVID-19 vaccines, testing, and treatment for Children’s Health Insurance Program (CHIP) members. This waiver will end on September 30, 2024
Providers may begin collecting co-pays for COVID-19 vaccines, testing, and treatment rendered to CHIP eligible members for dates of service on or after October 1, 2024.
Providers may not charge co-pays for mental health and substance use disorder outpatient office visits
Co-pays have been permanently removed for mental health and substance use disorder outpatient office visits to comply with federal regulations.
Superior Records Retrieval Project
It is always good to know things before they occur. But often we are scrambling for information after the fact.
NOT THIS TIME
Superior gives us a Heads Up.
Superior is requesting your cooperation in providing access to specific member records to facilitate a Risk Adjustment chart review. Risk Adjustment is the payment methodology used by CMS and HHS for Wellcare By Allwell and STAR+PLUS Medicare-Medicaid Plan.
The purpose of these chart reviews is to verify that information reported to Superior, and ultimately to CMS and HHS via claims or encounter data, includes all pertinent diagnosis codes at accurate levels of specificity.
Please Note: Superior has executed a Business Associate Agreement with both Advantmed and Datavant (formerly CIOX Health).
Advantmed and Datavant have been engaged by Superior to retrieve medical records selected as part of this chart review. Any information shared during this review will be kept in the strictest of confidence, in accordance with all applicable state and federal laws regarding the confidentiality of patient records, including current HIPAA requirements. Superior appreciates your cooperation with this and will work with you to minimize disruptions in member care.
You will have the option to submit medical records in the following ways:
- Secure email
- Fax
- FedEx
- Remote Electronic Medical Record (EMR) download
AND
- Onsite scanning performed by an Advantmed medical record technician
Tell your staff to anticipate a call or fax from Advantmed or Datavant to schedule the medical record retrieval in the upcoming weeks.
For any questions, please email [email protected]
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.
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