Complaint Information & Form

For information on the complaint process, please visit the Complaints and Appeals webpage.

Online Complaint Form

Please note that any field description with an asterisk (*) is required.

Member First Name *

Member Last Name *

Medicaid or CHIP ID Number *

First Name of Person Completing Form *

Last Name of Person Completing Form *

Other (please explain) *

Phone Number *

Street Address *

City *

State *

Zip Code *

Complaint Details

Other (please explain) *

Date Incident Occurred *

Is this complaint is related to Behavioral Health or Medical Health? * Behavioral Health Medical Health

What is your complaint? *

How can Superior resolve your issue? *

Please submit any relevant documentation to the complaint:

Attachment 1

Attachment 2

Attachment 3

Please note: Some documents may be too large to send through the Online Complaint Form. If you are not able to attach due to size, please send using one of the other options listed above.

By communicating with Superior HealthPlan via email, you give consent to receive information from Superior, which may contain Protected Health Information (PHI), to your email address. This consent is not required. Communication via email is not as secure as communicating via our secure member or provider portal.

If you agree to receive PHI information from Superior via email, please fill out the following field:

Name of Individual Completing this Form * (Member [you], Parent, Caregiver or Legally Authorized Representative of Member)

Provider First Name *

Provider Last Name *

Practice/Clinic/Facility Name *

Other (please explain) *

Provider Email Address *

Provider Phone Number *

Practice Street Address *

Practice City *

Practice State *

Practice Zip Code *

Are you a contracted provider? * Yes No

NPI Number *

Tax ID Number (TIN) *

Complaint Details

Other (please explain) *

Date Incident Occured * Use Date Format: XX/XX/XXXX

Is this complaint is related to Behavioral Health or Medical Health? * Behavioral Health Medical Health

What is your complaint? *

How can Superior resolve your issue? *

Please submit any relevant documentation to the complaint:

Attachment 1

Attachment 2

Attachment 3

Please note:

For claims-related complaints only: Claims detail and / or examples are required for a full review of the complaint to be completed.
Some documents may be too large to send through the Online Complaint Form. If you are not able to attach due to size, please send using one of the other options listed above.

This form will send your message to Superior HealthPlan as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Superior through email, you accept the risks associated thereof. Superior does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member Portal or Provider Portal, or you can call us at the Member Services number on the back of your Superior ID card to speak directly to a customer service representative.

By communicating with Superior HealthPlan via email, you give consent to receive information from Superior, which may contain PHI, to your email address. This consent is not required. Communication via email is not as secure as communicating via our secure member portal. If you do not want to receive email responses, please let us know.