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 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
Complaints Department
5900 E. Ben White Blvd.
Austin, TX 78741
Fax: 1-866-683-5369
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.
Member Appeals
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:
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.
Expedited Appeals
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.
Urgent Appeals
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.
Continuing Services
To continue services:
If the above are met, the services will continue until any of the following happen:
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.