Forms
Claims
- Claims Appeal (PDF)
- Claims Reconsideration (PDF)
- CMS1500 (PDF)
- Claim Status Request (PDF)
- Corrected Claim (PDF)
- UB04 (PDF)
Member Management
- Asthma Assessment Flow Sheet (PDF)
- Dental Therapy Under General Anesthesia (PDF)
- Medicare Dental Therapy Under General Anesthesia (PDF)
- Hysterectomy Acknowledgment (PDF)
- Medical Necessity Appeal (PDF)
- Member Advocate Referral (PDF)
- Notification of Pregnancy (PDF)
- Notification of Pregnancy (NOP) Incentive Program Details (PDF)
- Nursing Facility Service Notification Form (PDF)
- Primary Care Provider (PCP) Change Request Form (PDF)
- Private Payment Agreement (PDF)
- Specialist as PCP Request Form (PDF)
- Sterilization Consent Form Instructions - English (PDF)
- Sterilization Consent - English (PDF)
- Sterilization Consent - Spanish (PDF)
- Tuberculosis Screening and Education Tool - English and Spanish (PDF)
- Vision Care Eyeglass Patient Certification - English and Spanish (PDF)
Medicaid Prior Authorization Forms
- Allergen Extracts Prior Authorization Request (PDF)
- Attestation Form for Allergy and Immunology Therapy (PDF)
- Biopharmacy Outpatient Prior Authorization Form (J-code products) (PDF)
- Cover My Meds (PDF)
- Discharge Planning Prior Authorization Request (PDF)
- Hepatitis C – Initial Prior Authorization Request (PDF)
- Hepatitis C – Refill Prior Authorization Request (PDF)
- Prescriber Certification - Patient Education for Hepatitis C Treatment (PDF)
- Emergent Inpatient Notification (PDF)
- 2020 Inpatient Medicaid Authorization Form (PDF)
- Makena Prior Authorization Request (PDF)
- Non-Preferred VDP Prior Authorization Request (PDF)
- 2020 Outpatient Medicaid Authorization Form (PDF)
- PCSK9 Inhibitor Addendum (PDF)
- PCSK9 Inhibitor Prior Authorization Request (PDF)
- Provider Statement of Need – STAR+PLUS and STAR+PLUS MMP (PDF)
- Provider Statement of Need – STAR Kids and STAR Health (PDF)
- Provider Statement of Need Frequently Asked Questions (PDF)
- LTSS and Pharmacy Prior Authorization Request Form (PDF)
- Synagis® 2019-2020 Season – Prior Authorization Form (PDF)
- Texas Standard Prior Authorization Request (PDF)
- Texas Standard Pharmacy Prior Authorization Request (PDF)
Credentialing Verification Organization (CVO)
Superior requires the utilization of the statewide Texas Credentialing Alliance and the contracted Credentialing Verification Organization (CVO) as part of the credentialing and re-credentialing process. Please reference TAHP Introduction to the Texas Credentialing Verification Organization (PDF) or the TAHP Credentialing website.
Providers are required to complete the Texas Standard Credentialing Application (TSCA) for practitioners or the Superior Facility Credentialing Application for facilities.
- The Required 2007 TSCA is found on the Texas Department of Insurance website.(noted as Application Package)
- Aperture (the CVO services provider) will assist with a provider’s credentialing process for Superior HealthPlan. Credentialing documents are submitted to Aperture through CAQH or Availity.
- To submit a practitioner application to CAQH, go to the CAQH website. A practitioner will need to register as a first time user to get started.
- To submit a practitioner or facility credentialing application to Availity, go to the Availity website. Superior will accept the Facility and Ancillary Application (link below) as an alternative option to Availity, and will forward the application on to Aperture upon receipt.
- Once the completed application is processed through Availity or CAQH, Aperture automatically retrieves the submitted information and performs the primary source verifications of submitted credentials.
- Aperture verifies the credentialing application and returns results to Superior for a credentialing decision.
Credentialing
- Behavioral Health Facility and Ancillary Credentialing Application (PDF)
- Individual and Group Provider Credentialing Application (PDF)
- Facility and Ancillary Application (PDF)
- Hospital Credentialing Application (PDF)
- Join Our Network
MMP Prior Authorization Forms & Information
- Drug Coverage Determination Form (PDF)
- LTSS and Pharmacy Inpatient Prior Authorization Form (PDF)
- LTSS and Pharmacy Outpatient Prior Authorization Form (PDF)
- 2020 Inpatient Prior Authorization Form (PDF)
- Medicare Part B Prior Authorization List (PDF)
- 2020 Outpatient Prior Authorization Form (PDF)
- Prior Authorization Criteria (PDF)
- Prior Authorization Form Instructions (PDF)
- Provider Fax Back Form (PDF)
- Quantity Limit Listing (PDF)
- STAR+PLUS MMP Prior Authorization List (PDF)
- Step Therapy Criteria (PDF)
Medicare Claims Forms and EDI Tools
- Corrected Claim Form (PDF)
- Waiver of Liability Statement (PDF)
- 5010 837P/I Companion Guide (PDF)
- 5010 Companion Guide Addendum A (PDF)
- 835 Claim Adjustment Reason Codes Crosswalk to EX Codes (PDF)
- EDI Audit Report Claim Rejection Codes (PDF)
- EDI COB Mapping Guide (PDF)
- NPI Billing Requirements (PDF)
Medicare Acute Care Services
- LTSS and Pharmacy Inpatient Prior Authorization Fax Form (PDF)
- LTSS and Pharmacy Outpatient Prior Authorization Fax Form (PDF)
- Prior Authorization Requirements (PDF)
- 2020 Inpatient Prior Authorization Fax Form (PDF)
- 2020 Outpatient Prior Authorization Fax Form (PDF)
Helpful Medicare Links
- Medicare Links (PDF) - (Please note: By clicking on the links below you will be leaving the Superior HealthPlan website.)
- HMO Drug Coverage Determination Form (PDF)
- HMO SNP Drug Coverage Determination Form (PDF)
Ambetter Forms
- To locate Ambetter from Superior HealthPlan Provider Forms, please visit Ambetter's Provider Resources.
Behavioral Health
- To locate Behavioral Health forms, please visit Superior's Behavioral Health Resources.
Provider Services
Texas Health Steps
- CCP ECI Request for Initial/Renewal Outpatient Therapy (PDF)
- Dental Mandatory Prior Authorization Request (PDF)