Superior members have access to all Medicaid and CHIP covered benefits that are medically necessary health-care services. Some of these services need to be reviewed before the service is provided to make sure the service is appropriate and medically necessary. This review is called prior authorization, and is made by doctors, nurses and other health-care professionals. If a prior authorization request cannot be approved based on medical necessity, you will receive a letter with the reason why the prior authorization request was not approved. This is called an adverse determination (medical necessity denial). You can ask Superior to review the prior authorization request again. This is called an appeal of the adverse determination.
A list of the Medicaid and CHIP covered services that require prior authorization may be found by visiting:
CHIP prior authorization approval and denial rates for the medical care or health-care services may be accessed by visiting:
To review the Medicaid prior authorization annual review report, please reference:
Health-care providers are responsible for submitting prior authorization requests. These requests can be submitted by phone, fax or online, using Superior’s Secure Provider Portal. Your provider can also get more information by visiting Superior’s Medicaid and CHIP Prior Authorization Requirements webpage.
Review the information below to learn more about which services may need prior authorization approval before the service is provided. If you have any questions, please call Member Services (Monday-Friday, 8 a.m. – 5 p.m.):
Prior authorization decisions are made using generally-accepted clinical practices, which include the special needs of each case that may require an exception to the standard. Clinical screening criteria are used to review the medical necessity of the requested service.
The following clinical guidelines are used to make medical necessity decisions, on a case-by-case basis, based on each member’s health status, as appropriate:
To find clinical policy screening criteria for certain service types, visit Superior’s Clinical Policy webpage.
If the medical necessity of a prior authorization cannot be confirmed by clinical staff, a Texas-licensed physician/medical director reviews the case. This review includes the option for a peer discussion with the rendering/ordering provider who ordered the service before making any adverse determination.