Forms
Claims
- Claims Appeal (PDF)
- Claims Reconsideration (PDF)
- CMS1500 (PDF)
- Corrected Claim (PDF)
- Request for Claim Status (PDF)
- UB04 (PDF)
Member Management
- Acknowledgement of Consenting Person/Surrogate Decision-Maker (PDF)
- Asthma Assessment Flow Sheet (PDF)
- Dental Therapy Under General Anesthesia (PDF)
- Hysterectomy Acknowledgment (PDF)
- Medicare Dental Therapy Under General Anesthesia (PDF)
- Medical Necessity Appeal (PDF)
- Medical Necessity and Level of Care Assessment Physician’s Signature (PDF)
- Medical Necessity and Level of Care Assessment Physician's Signature FAQs (STAR+PLUS and MMP) (PDF)
- Member Advocate Referral (PDF)
- Notification of Pregnancy - Provider Form (PDF)
- Notification of Pregnancy (NOP) Incentive Program Details (PDF)
- Nursing Facility Service Notification Form (PDF)
- Physician Certification (2601 Form) (PDF)
- Physician Certification (2601 Form) FAQs (STAR Kids and STAR Health) (PDF)
- Prescription Claim Reimbursement 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
- Inpatient Medicaid Authorization Form (PDF)
- Outpatient Medicaid Authorization Form (PDF)
- Biopharmacy Outpatient Prior Authorization Form (J-code products) (PDF)
- Cover My Meds (PDF)
- Discharge Medication Referral Form (PDF)
- Discharge Planning Prior Authorization Request (PDF)
- Emergent Inpatient Notification (PDF)
- Non-Preferred VDP Prior Authorization Request (PDF)
- PCSK9 Inhibitor Addendum (PDF)
- PCSK9 Inhibitor Prior Authorization Request (PDF)
- Provider Attestation Statement: Allergy Skin Testing and Immunotherapy for Non-Allergist (PDF)
- Provider Statement of Need Frequently Asked Questions (PDF)
- Provider Statement of Need – STAR+PLUS and STAR+PLUS MMP (PDF)
- Provider Statement of Need – STAR Kids and STAR Health (PDF)
- Synagis® Season – Prior Authorization Form (PDF)
- Texas Standard Prior Authorization Request (PDF)
- Texas Department of Insurance (TDI) Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF)
- TMHP CCP Prior Authorization Private Duty Nursing 6-Month Authorization Form (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)
- Verisys (the CVO services provider) will assist with a provider’s credentialing process for Superior HealthPlan.
- Practitioner credentialing documents are submitted to Verisys through CAQH. 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. Once the completed practitioner application is processed through CAQH, Verisys automatically retrieves the submitted information and performs the primary source verifications of submitted credentials.
- Facilities may submit the Texas Facility Credentialing Application to Verisys using the methods listed below. Alternatively, Superior will accept the Facility and Ancillary Application (link below) and will forward the application to Verisys upon receipt.
- Verisys Texas Facility Credentialing Application submission (application must have barcode):
- Email: TAHPapps@verisys.com
- Fax: 1-866-293-0421
- Mail: PO Box 221049, Louisville, KY, 40252-1049
- Verisys Texas Facility Credentialing Application submission (application must have barcode):
- Verisys verifies the credentialing application and returns results to Superior for a credentialing decision.
Credentialing
- Behavioral Health Disclosure of Ownership and Control Interest Statement (PDF)
- Behavioral Health Facility and Ancillary Credentialing Application (PDF)
- Behavioral Health Provider Specialty Profile (PDF)
- Form 1600 - Permission to Allow Superior HealthPlan to Request Child Abuse/Neglect Central Registry can be found on the DFPS Forms webpage.
- Facility and Ancillary Application (PDF)
- Group National Provider Identifier (NPI) Demographic Form - Mental Health Rehabilitation and Targeted Case Management (MHR/TCM) (PDF)
- Hospital Credentialing Application (PDF)
- Individual and Group Provider Credentialing Application (PDF)
- Join Our Network
- Mental Health Rehabilitation and Targeted Case Management Annual Attestation (MHR/TCM) (PDF)
MMP Prior Authorization Forms & Information
- Inpatient MMP Authorization Form (PDF)
- Outpatient MMP Authorization Form (PDF)
- Drug Coverage Determination Form (PDF)
- Medicare Part B Prior Authorization List (PDF)
- STAR+PLUS MMP Prior Authorization
- Prior Authorization Form Instructions (PDF)
- Prior Authorization, Step Therapy and Quantity Limits webpage
- Provider Fax Back Form (PDF)
- Quantity Limit Listing (PDF)
- STAR+PLUS MMP Prior Authorization List (PDF)
- MMP Waiver of Liability Statement (PDF)
Medicare Claims Forms and EDI Tools
- 5010 837P/I Companion Guide (PDF)
- 5010 Companion Guide Addendum A (PDF)
- 835 Claim Adjustment Reason Codes Crosswalk to EX Codes (PDF)
- Claims Reconsideration Form (PDF)
- Corrected Claim Form (PDF)
- EDI Audit Report Claim Rejection Codes (PDF)
- EDI COB Mapping Guide (PDF)
- NPI Billing Requirements (PDF)
- Waiver of Liability Statement (PDF)
Medicare Acute Care Services
- Inpatient Medicare Authorization Fax Form (PDF)
- Outpatient Medicare Authorization Fax Form (PDF)
- To access prior authorization lists, please visit Superior’s Prior Authorization Requirements webpage.
Helpful Medicare Links
- Drug Coverage Determination Forms (HMO and HMO DSNP)
- Hospice Information for Medicare Part D Plan (PDF)
- Medicare Links (PDF) - (Please note: By clicking on the links below you will be leaving the Superior HealthPlan website.)
Ambetter Forms
To locate Ambetter from Superior HealthPlan Provider Forms, please visit Ambetter's Provider Resources or Ambetter's Pharmacy webpages.
Behavioral Health
To locate Behavioral Health forms, please visit Superior's Behavioral Health Resources.