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Grievance and Appeals
Provider Complaint Process
A Complaint is a written expression by a provider which indicates dissatisfaction or dispute with Ambetter's policies, procedure, or any aspect of Ambetter's functions. Ambetter logs and tracks all complaints received in writing. After a complete investigation of the complaint, Ambetter shall provide a written response to the provider within thirty (30) calendar days from the received date of the complaint. If the complaint/grievance is related to claims payment, the provider must follow the process for claim reconsideration or claim dispute as noted in the Claims section of the Provider Manual prior to filing a Complaint.
Member Complaint/Grievance and Appeal Process
To ensure that Ambetter member's rights are protected, all Ambetter members are entitled to a Complaint/Grievance and Appeals process. The procedures for filing a Complaint/Grievance or Appeal are outlined in the Ambetter member's Major Medical Expense Policy. Additionally, information regarding the Complaint/Grievance and Appeal process can be found on our website at Ambetter.SuperiorHealthPlan.com or by calling Ambetter at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
Member Complaints may be made by calling Member Services at 1-877-687-1196 (Relay Texas Relay Texas/TTY 1-800-735-2989). A complaint acknowledgement letter will be sent to the member within five days, along with an oral complaint form. This form needs to be completed and returned to Ambetter for us to proceed with the processing of the member complaint. If the member has questions, we can help the member complete the form.
Written complaints can be sent on paper or electronically. To file the member complaint, send to:
Ambetter from Superior HealthPlan
5900 E. Ben White Blvd.
Austin, TX 78741
The member may also access the member complaint form online (PDF).
The member will be notified within five business days that the complaint has been received. Expedited complaints concerning emergencies or denial of continued hospitalization will be resolved within one (1) business day from receipt of the complaint, or earlier, depending on the medical immediacy of the case. The member will receive a letter with the resolution to the member complaint within three (3) business days.
Members submitting non-expedited complaints will receive a letter with the resolution within thirty (30) calendar days of receipt of the complaint. If the member is not satisfied with the complaint resolution, within (30) days, the member can request an appeal of the complaint resolution. In response to the member complaint appeal, a complaint appeal panel including Ambetter staff, provider(s) and member(s) will be held at a site where the member normally receives healthcare or at another site agreed to by the complainant, upon request. A hearing packet will be sent to the member five (5) days before the appeal panel hearing is held. The member may attend the hearing, have someone represent the member at the hearing, or have a representative attend the hearing with the member. The panel will make a recommendation for the final decision on the member complaint, and Ambetter’s final decision will be provided to the member within thirty (30) days of the member’s complaint appeal request.
The member may also file a complaint with the Texas Department of Insurance (TDI). There are several ways to file a complaint with TDI:
- Visit www.tdi.texas.gov and fill out a complaint form.
- Send an email to ConsumerProtection@tdi.texas.gov.
- Mail the member complaint to:
Texas Department of Insurance
Consumer Protection Section (MC 111-1A)
P.O. Box 149091
Austin, TX 78714-9091
Ambetter will never retaliate against the member because the member filed a complaint, or appealed the decision. Similarly, Ambetter will never retaliate against a physician or provider because the provider has, on the member’s behalf, filed a complaint or appealed a decision.
The member can request an appeal within one hundred and eighty (180) calendar days of receipt of a medical necessity denial of medical or behavioral health services.
Ambetter will send the member a decision regarding the member’s appeal:
- Expedited – Within one (1) working day for life threatening, urgent or inpatient services
- Standard – Within thirty (30) days
The appeal decision will be made by a physician who has not previously reviewed the case nor is supervised by a physician who has reviewed the case before.
If the member appeal is denied, the member also has the right to request an External Review.
The member has the right to request an expedited appeal if the denial was for emergency care or for a continued hospital stay. We will process the expedited appeal based on the member’s medical condition, procedure or treatment under review. The answer will be completed within one (1) working day or seventy-two (72) hours from the date all needed information is received.
The member can also request an expedited appeal for an urgent care denial. The member can do this if the member thinks the denial could seriously hurt the member’s life or health, or if the member’s Provider thinks that this denial will result in severe pain without the requested care or treatment provided. The decision regarding the member’s appeal for urgent care will be issued within seventy-two (72) hours of the member’s request.
Ambetter must agree with the member’s request that waiting thirty (30) days for a standard appeal could put the member’s life or health in danger. If we do not agree, we will let the member know. The member’s request would then go through the regular process. The member will get a response in thirty (30) days.
To continue services:
- The member must request an appeal by the latter of: 1) Ten (10) days after the date of the original denial letter; or 2) the day the appealed service will be reduced or ended.
- The member must state in the member request that the member wants to continue services.
- The denied services must have been previously authorized.
- The time period covered by the original authorization must not have ended.
If the above are met, the services will continue until any of the following happen:
- The member cancels the appeal.
- The member’s appeal is denied.
- The appeal decision has been rendered as denied.
If the member’s appeal is not approved, the member may be financially responsible for the continued services.
External Review Process
Getting an External Review is a process that allows members to have their concerns reviewed by a third party. If we have denied an appeal for a service the member or provider has requested, the member can submit a request for External Review, and independent reviewers will look at the case. Members must complete the appeal process with Ambetter before they can submit a request for External review.
Send requests for External Review directly to MAXIMUS at:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Fax number: 1-888-866-6190
Members can view the Major Medical Expense Policy for full complaint and appeal procedures and processes, including specific filing details and timeframes. Members can access the Major Medical Expense Policy in their online member account.