Applies To

Pediatric Specialists - All MEDICAID Enrolled Faculty at CMC that may see a patient for care or treatment at CMC or the CMC clinics, not Aston.

Except:

•   Psychiatry
•   Vision Services

UTSWMCD has contracted with Superior HealthPlan, Inc. for the CHIP program in the State of Texas for tertiary care only, which provides for pediatric patients seen at CMC facility/clinics, by our UTSW CMC providers only. Authorizations are still required. This agreement does not include pediatric services at MROC, the CPC, or for any transplant services.

PCP Services

Specialty services only, no PCP.

Laboratory Services

Only services at CMC or CMC Clinics.

Radiology Services

Only services at CMC or CMC Clinics.

Participating Facilities

Children’s Medical Center

Referral Requirements

Not applicable to this agreement. Authorizations are always required.

Authorization Requirements

An Authorization is required for every visit/treatment rendered at CMC or at the CMC clinics.

To verify an authorization contact Medical Management at 1-800-218-7508 fax information to 512-692-1438.

Managed Care Plan

HMO - CHIP Program in Texas (only covers patients who have chosen Superior HealthPlan CHIP-EPO)

Identification Card
 

See provider manual for an example, attachment 3-C.

FSC

CHIP – 497, registration FSC

Contract Date(s)

September 1, 2006

Eligibility

Contact Superior’s Member Services Department at

1-800783-5386.

See Section 5 for a list of CHIP Program Benefits, Exclusions, and DME/Supplies covered under this agreement.

Claims Mailing Address

Electronic payor ID is SHP11.

Superior Health Plan, Inc.
P.O.Box 3003
Farmington, MO  63640-3803

Deductible/Co-Payment

Copay (s) may apply, and varies by member. Please review the patient’s ID Card for the applicable amount to collect at the time-of-service.

Claims Submission

• Claims should be submitted on a standard CMS 1500 claim form.
• Claims must be received within 95 days of the date of service, after this deadline the claim will be denied for payment.
  
  

Claims Payment

• Superior CHIP-EPO will pay clean claims within 45 days of receipt.
  
  

Appeals

Superior HealthPlan

Attn: Appeal Coordinator
2100 IH-35 South, suite 202
Austin, Texas  78704

Effective August 1, 2004, providers must file appeals or adjustment requests within 120 days from the date of disposition.

Provider Relations

CHIP, 1-877-391-5921 option 3 or fax# 1-915-778-5688
and website, www.superiorhealthplan.com .

Comments

• Enrollment is through Maximus (800) 964-2777
• Superior Behavioral Health is Tejas Behavioral Health Services and can be contacted at 1-800-716-5650.
• Superior’s vision plan is AECC/Total Vision and they can be reached at 1-888-756-8768.