If you do not request an External Medical Review within 10 days from the time you get the appeal decision from Superior, the service Superior denied will be stopped. Appeals and Grievances. We want to help. 5900 E. Ben White Blvd., Medicaid Fraud Control Unit | Office of the Attorney General All rights reserved. You have the right to keep getting any service the health plan denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made if you ask for a State Fair Hearing by the later of: (1) 10 calendar days following the date the health plan mailed the internal appeal decision letter, or (2) the day the health plans internal appeal decision letter says your service will be reduced or end. If Superior thinks that your emergency appeal request does not meet the emergency appeal criteria, Superior will let you know right away. Written complaints can be sent on paper or electronically. The No Surprises Act is a federal law that went into effect on January 1, 2022. You, your provider or another person acting on your behalf can file an appeal. You can send an internal health plan appeal in writing to: Superior HealthPlan You can ask for an External Medical Review and a State Fair Hearing, but you cannot request only an External Medical Review. Telephone. Superior will make a decision about your expedited appeal within one (1) Business Day, and send you a letter within 72 hours. To ensure coverage continues, if you're eligible, report changes (contact information, pregnancy, etc.) Medicare (doctors, hospitals, plans, quality of care, medical equipment): Medicare.gov. Texas STAR Frequently Asked Questions | UnitedHealthcare Community Plan The .gov means its official. by using this system you acknowledge and agree that you have no right of privacy in connection with your use of the system or your access to the information contained within it. By communicating with Superior HealthPlan via email, you give consent to receive information from Superior, which may contain PHI, to your email address. Efforts by the Medicaid Fraud Control Unit (MFCU) of the Office of the Attorney General of Texas (OAG) have led to a home health company owner being sentenced to prison for 57 months. Contact CMS | CMS - Centers for Medicare & Medicaid Services The investigator determines whether a complaint represents a violation of Medicaid policy or federal and state law or regulation. Effective July 27, 2023: Texas Medicaid Preferred Drug List Updates HHSC may need to send you a notice that your . To ensure coverage continues, if you're eligible, report changes (contact information, pregnancy, etc.) Sign up to receive our weekly newsletter and get all the latest news and updates, including the most recent episode of AFMC TV, right to your inbox! We can also help with most types of insurance, but not all. An External Medical Review is an optional, extra step you can take to get the case reviewed before the State Fair Hearing occurs. Write a letter addressed to Client Correspondence including the date you told the provider you/your child are/is a client of Texas Medicaid. If you have a health or dental plan, call your health or dental plan first. You may file appeals through the following methods: Phonethrough the TMHP Contact Center at 1-800-925-9126. You have the right to appeal Superiors decision if CHIP covered services are denied based on lack of medical need. It is important that you or your representative attend the State Fair Hearing in person or by phone. Fax: 1-866-683-5369. The investigation was conducted by Sergeant Alfred Paige, Investigative Auditor Daryl Middleton, and Captain Alexander Chancia of the Texas Attorney Generals Medicaid Fraud Control Unit (MFCU), in cooperation with the FBI and the Department of Health and Human Services - Office of Inspector General. You can also complain to the Texas Health and Human Services Commission (HHSC) by emailing. It applies to most types of health insurance, and protects you from unexpected out-of-network medical bills from: Emergency room visits. Needs: This column refers to what youre looking for, like Rent Payment Assistance or Food Pantries. FAX:1-866-918-2266. If you have questions about prior authorization requests, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413. 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. A complaint acknowledgement letter will be sent to you within five (5) days. An External Review is an outside review of your health plans denial of a service you and your doctor feel is medically necessary. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review. Date: 06/22/23. Your appeal is for a service that was denied or limited that had been previously approved. Administrative Appeals (for Medicaid providers) You may file appeals through the following methods: Electronicallythrough your TMHP My Account. To continue receiving a service that is being ended, suspended or reduced, your request to continue a service must be made within ten (10) calendar days of the date of Superiors Notice of Adverse Benefit Determination letter, or before the date services currently authorized will be discontinued, whichever is later. Superior will send you a letter if a requested service that requires authorization is denied or limited. Phone: 888-303-6162 Email: CentralPRTeam@uhc.com. But heres where you can go for questions or complaints about: Body shops: Texas Attorney General 800-621-0508 File a complaint, Tow truck companies: Texas Department of Licensing and Regulation 800-803-9202 File a complaint. people who are 20 or younger. The email is not encrypted and is not transmitted in a secured format. Complaints and Appeals | Texas Medicaid | Superior HealthPlan Communication via email is not as secure as communicating via our secure member portal. 01_Contact_Info - TMHP If you continue with a State Fair Hearing and the State Fair Hearing decision is different from the Independent Review Organization decision, it is the State Fair Hearing decision that is final. If you need help, Superior can help you put your appeal in writing. Texas Medicaid renewals are coming back. Beginning September 1, 2021, MCCO instructed the MCOs to begin submitting all transportation related complaints on the monthly flat-file. Eligibility questions call 2-1-1, Option 2, Medicaid benefits questions your health plan, All other questions HHS Ombudsman, 866-566-8989. State and federal government websites often end in .gov. Is stopping coverage for care you think you/your child needs. Organization. An Independent Review Organization is a third-party organization contracted by HHS that conducts an External Medical Review related to Adverse Benefit Determinations based on functional necessity or medical necessity. Programs: The names of the programs that various organizations offer. If you need additional claim status and denial information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413. or Insurance Premium Payment Assistance questions, TMHP HIPP/IPPA Client Helpline8004400493 You can make both of these requests by contacting Superior at 1-877-398-9461 or the HHS Intake Team at EMR_Intake_Team@hhsc.state.tx.us. You, your provider or another person acting on your behalf can file an appeal. Start your online complaint with HHS-OIG by selecting an option below. The defendants are also accused of offering illegal kickbacks to marketers and caregivers of Medicaid-insured children, enticing them to bring the children to Floss for fraudulent dental services. You may submit an Administrative Review within 30 days of the date of the denied authorization. PDF Tmhp and Hhsc Contact Information Dial 2-1-1or (877) 541-7905 | Chat now in English | Chatear ahora en Espaol, Medicaid Members:Continuous Medicaid coveragehas ended and Medicaid renewals have started, effective April 1, 2023. If you have concerns or are unhappy with your health or dental plan or the services you receive, you can submit a complaint. An expedited appeal is when Superior HealthPlan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health. A Superior Member Advocate can help you with any questions you may have related to an expedited appeal. You or your representative must ask for the External Medical Review within 120 days of the date Superior mails the letter with the internal appeal decision. OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services programs. For information about COVID-19, call 2-1-1, Option 1. You can also ask for an emergency appeal in writing and send it to Superiors Medical Management department at: Superior HealthPlan (7 a.m. to 7 p.m. Central Time, Monday to Friday). You can also call if you need help finding a doctor, scheduling an appointment, getting a new ID card or accessing benefits and services. To request an External Review, you must provide the following information: name, address, phone number, email address, whether the request is expedited or standard, a completed Appointment of Representative Form (if someone is filing on your behalf) and a brief summary of the reason you disagree with Superiors decision. Superior will acknowledge your appeal within five (5) Business Days of receipt, and complete the appeal within 30 calendar days. Medicaid can only pay enrolled providers for the services they perform. PDF How to Submit a Complaint - Texas Health and Human Services The remaining 25 percent, totaling $6,981,395, is funded by the State of Texas. Call or write us! Complaints Department If you need help understanding the language being spoken, Superior has people who can help you on the phone or can go with you to a medical appointment. 7.1 Appeal Methods An appeal is a request for reconsideration of a previously dispositioned claim. Interpreter services are provided free of charge, call Member Services for assistance. If you continue with the State Fair Hearing, you can also request the Independent Review Organization be present at the State Fair Hearing. (7 a.m. to 7 p.m. Central Time, Monday to Friday), Supplemental Security Income (SSI) questions, Social Security Administration8007721213, TMHP Personal Care Services Line8882760702. We use this information to make sure we know who you are and the details of your case are secure. (8 a.m. to 6 p.m. Central Time, Monday to Friday), Health Insurance Premium Payment Program By mailfind the correct address in the appeals section of the. Contact Us - TMHP If you are a member of the media, please send your questions to mediainquiries@superiorhealthplan.com. Please note that collection statements are not considered bills. Superior does not accept responsibility or liability for any loss or damage arising from the use of email. You can also the name of the organization if you dont know the program, End of Continuous Medicaid Coverage | Texas Health and Human Services, Department of Family and Protective Services, Texas Health and Human Services Commission. Your name or the name of the person you are calling about. You can also call if you need help finding a doctor, scheduling an appointment, getting a new ID card or accessing benefits and services. Welcome Texas Medicaid Providers | TMHP To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member Portal or Provider Portal, or you can call us at the Member Services number on the back of your Superior ID card to speak directly to a customer service representative. To remain truly anonymous, you are encouraged to make the report online through ReportTexasFraud.com. Secure .gov websites use HTTPS Medicaid: 800-252-8263. Getting to the doctor, dentist or drugstore. If you, as a member of Superior, disagree with our internal appeal decision, you have the right to ask for an External Medical Review. If you suspect Medicaid fraud or abuse, or patient neglect, please report it by visiting the OAGs website. If the complaint is Medicaid-related and contains sufficient provider-identifying information, a case is opened and assigned to an intake investigator. Just call Member Services. For every dollar of state funding, the OAG's MFCU recovers more than 33 dollars for taxpayers. Emergency appeals do not have to be in writing. If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Superiors denial is called an Adverse Benefit Determination. You can appeal the Adverse Benefit Determination if you think Superior: You, a provider or someone else acting on your/your childs behalf can appeal an action. You will be notified of the appeal decision within one (1) business day for denials of on-going emergency or denial of continued hospital stay. Medicaid Complaints - uhc If the provider is enrolled and you are covered for the date(s) of service, follow the steps under the If You Receive a Bill section of the TMHP. Written complaints can be sent on paper or electronically. The defendants are charged with defrauding the Medicaid program through illicit practices committed through the Floss Family Dental Care clinic in Houston. Important Telephone Numbers | TMHP MAXIMUS will also send a written version of the decision within 48 hours of the phone call. You are hereby advised that electronic mail and online chat messages sent through this website are not inherently secure from misdirection or interception by third parties, and that electronic mail and online chat messages sent to TMHP must not contain any private information or confidential patient data. Beginning September 1, 2021, MCCO instructed the MCOs to begin submitting all EVV related complaints on the monthly flat-file. You may submit through the following methods: You can verify client eligibility using the Automated Inquiry System (AIS), the Interactive Voice Response (IVR), or through a representative by calling the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413. Request Network Participation, Non-Contracted Providers Only, Add a Provider to an Existing Group Contract, Add a Practice Location to an Existing Contract, Practice Improvement Resource Center (PIRC), Updating Provider Demographic Information, Effective 1/1: Electronic Prescribing of Controlled Substances Required, Effective September 1, 2021: Benefit Changes to Total Disc Arthroplasty for Medicaid and CHIP, Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization Requirements for DME, Orthotic, and Enteral/Parenteral Nutrition and Medical Supplies, Javelina legend and NFL hall of famer Darrell Green gives back to Kingsville, Superior HealthPlan, Pro Football Hall of Famer Darrell Green Help Make First Back-to-School Community Fair & Fest in Kingsville a Success, Provider Notice of Adverse Benefit Determinations, Superior to Override Timely Filing for Claims Impacted by Texas Medicaid Healthcare Partnerships (TMHP) Eligibility Verification Issues, HHS Federal External Review Request Form (PDF). If you would like to make your request online or in writing, send it to the addresses listed on the Texas Department of Insurance website. From 2019 to 2021, the dental clinic fraudulently billed Medicaid approximately $6.9 million. ATTN: Medical Management Web Address. Call Superior Member Services for more information. Log in to your account and send us a message. If you need help with claim rejections, issues with your account, or other questions, call the TMHP EDI Help Desk at 1-888-863-3638. You can ask for an internal health plan appeal within 60 Days from the date of Superiors Notice of Adverse Benefit Determination letter. Finding services in your area such as child care. How to File a Complaint - Molina Healthcare If you aren't satisfied with the answer to your complaint, you can also contact the Texas Department of Insurance: By phone: 1-800-252-3439. How to file a health insurance complaint - Texas Department of Insurance If you don't have a health or dental plan, call the Medicaid helpline at 800-335-8957. If you call during our regular hours and we cant get to the phone, you can also leave a message. After a Medicaid member has completed the internal health plan appeal process related to an adverse benefit determination, more appeal rights are available to a member if he/she is not satisfied with the health plans appeal decision. To file a Medicaid complaint, contact the Austin headquarters. Request assistance from TMHP by forwarding the bill(s) to the Client Correspondence Unit. North Austin Complex Note: TDI regulates Medicare supplement insurance and can help with questions or complaints. To ask for a fair hearing, call 1-800-414-3406 or write to: TMHP Portal Security Provider Training Manual, Texas Medicaid Provider Procedures Manual, Children with Special Health Care Needs Services Program Provider Manual, Learn more about Medicaid and Your Texas Benefit Card. Use this form to help us ensure that the Provider data on our Find a Provider tool is accurate. Other important information, such as birthdays or home addresses. In Texas, Medicaid costs taxpayers over $40 billion. On June 1, 2021, MCCO, in association with contracted MCOs, implemented HB 1576, Delivery of NEMT services by MCOs. Medicaid Complaints and Appeals - MCNA Dental: Texas Medicaid and CHIP Important: You cannot file claims, appeals nor administrative reviews through the complaint process. Mail the copy of the bill and your letter to Client Correspondence. TDI doesnt regulate service providers, like body shops and tow truck companies. There is no cost to you for an External Review. Box 165089. 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. What is the Medicaid Fraud Control Unit? Not sure who to call with your question or complaint? If you are not satisfied with the complaint resolution, within thirty (30) days, you can request an appeal of the complaint resolution. Pittsford, NY 14534. On January 1, 2021, HHSC required Electronic Visit Verification (EVV) for all Medicaid personal care services as mandated by the federal 21st Century Cures Act. 2019 Legislative Session Update for Victims and Service Providers, 2021 Legislative Session Open Government Update. A fair hearing is a chance for you to tell us the reasons you think you should have a Medicaid service you asked for but did not get. End of Continuous Medicaid Coverage | Texas Health and Human Services 800-335-8957 You have the right to appeal Superiors decision if Medicaid covered services that require authorization are denied, reduced, suspended or ended. This could be a doctor, relative, friend, lawyer, or any other person. If your complaint is about a doctor's office, pharmacy or medical equipment company, have their contact information handy. If you are unhappy with Superior, you may file a complaint (PDF). As a member of Superior HealthPlan, you can call Member Services if you have questions about your health plan. Call 866-566-8989 8 a.m. to 5 p.m. Central Time, Monday through Friday and speak to someone that day. Tips from the public to the OIG Fraud Hotline help ensure that Texas Medicaid funds are not lost to fraud. Contact Us | UnitedHealthcare Community Plan of Texas - UHCprovider.com By mail: Texas Department of . To ask for a State Fair Hearing, you or your representative should write or call Superior: Contact | TMHP Box 1427 Milwaukee, WI 53201 Can someone from UnitedHealthcare Dental help me file a complaint? You can also ask for an expedited appeal in writing and send it to Superiors Appeal Department by fax at 1-866-918-2266. Due to the high volume of complaints we receive, it is not possible to contact every complainant. TDI can help with questions and complaints about insurance companies, agents, and adjusters that we regulate. 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 (HHS) with or without an External Medical Review through an Independent Review Organization (IRO). You may represent yourself at the State Fair Hearing, or name someone else to be your representative. Texas Health Steps8778478377 The managed care organization (MCO) is required to provide HHSC with operational data necessary to consistently evaluate the EVV system and monitor the impact of improvements made to the EVV system and EVV processes. Have any documents related to your complaint, such as letters, bills or prescriptions, ready too. Your appeal is for a service ordered by a Superior approved provider. Complaints may be made by calling Superior Member Services at the number on the back of your ID card (Relay Texas 1-800-735-2989). Call your provider's office right away to make sure they know you or your child are on Medicaid or the CSHCN Services Program and that they have your client ID number. Callers are asked to provide contact information, which is used if an investigator has further questions. Texas Health and Human Services. You can file claims on paper or electronically. Contact Us The Department of State Health Services (DSHS) strives to improve the health, safety, and well-being of all Texans. We recommend you review Before You Submit a Complaint to understand the type of complaints we do and do not investigate and the complaint process.
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