Orlando Harmon
If you are dissatisfied with an Ambetter insurance payment, you can appeal the decision. Ambetter members can file a complaint or grievance, and the procedures for doing so are outlined in the Major Medical Expense Policy. You can also call Ambetter at 1-877-687-1196 or submit a written complaint electronically or on paper. If you are appealing a claim denial, you must submit a claim reconsideration within 180 calendar days from the date of the original Explanation of Payment (EOP) or denial. You can submit a reconsideration request through the Secure Provider Portal, by phone, or by mail. If you are still unsatisfied with the complaint resolution, you can request an appeal within 30 days.
| Characteristics | Values |
|---|---|
| Who can appeal | Members, providers, physicians |
| Time limit for appeal | 30 days after the complaint resolution, 180 calendar days for denial of medical or behavioral health services |
| Where to send the appeal | Texas Department of Insurance Consumer Protection, MC: GC-CCO P.O. Box 12030 Austin, TX 78711-2030 |
| How to appeal | By phone, mail, or online |
| Appeal process | A complaint appeal panel including Ambetter staff, provider(s) and member(s) will be held at a site where the member normally receives healthcare. The member will receive Ambetter's final decision within 30 days of the appeal request. |
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What You'll Learn
Ambetter grievance and appeals forms and processes
Ambetter from Superior HealthPlan has outlined procedures for filing a complaint, grievance, or appeal. These procedures are included in the Ambetter member's Major Medical Expense Policy. Additional information on the complaint/grievance and appeal process can be found on the Ambetter website or by calling Ambetter at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).
A complaint is a written expression by a provider that indicates dissatisfaction or dispute with Ambetter's policies, procedures, or any other aspect of Ambetter's functions. Ambetter logs and tracks all written complaints. After a thorough investigation, Ambetter will provide a written response to the provider within thirty calendar days of receiving 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 before filing a complaint.
To file a member complaint, one can call Member Services at 1-877-687-1196 (Relay Texas Relay/TTY 1-800-735-2989). Within five days, the member will receive a complaint acknowledgment letter along with an oral complaint form. This form must be completed and returned to Ambetter for them to proceed with processing the member complaint. Ambetter can help the member complete the form if they have any questions. Written complaints can be sent on paper or electronically to the Ambetter from Superior HealthPlan Complaints Department.
If the member is dissatisfied with the complaint resolution, they can request an appeal within thirty days. In response to the member complaint appeal, a complaint appeal panel, including Ambetter staff, providers, and members, will be held at a site where the member normally receives healthcare or another agreed-upon site. The member will receive a hearing packet five days before the appeal panel hearing. The member may attend the hearing, have someone represent them, or have a representative attend with them. The panel will make a recommendation, and Ambetter will provide its final decision to the member within thirty days of the member's complaint appeal request. The member may also file a complaint with the Texas Department of Insurance (TDI).
Additionally, a member can request an appeal within 180 calendar days of receiving a denial of medical or behavioral health services. Ambetter will send an appeal decision to the member, which will be made by a physician who has not previously reviewed the case.
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Retrospective reviews
Retrospective Review is a process that allows for the review of care or services already provided to a member, including acute hospital stays. This process requires the submission of a claim for payment, supported by relevant documentation such as medical records, certificates of medical necessity, consent forms, or invoices. If the claim is denied, providers can file a claim reconsideration.
The member complaint process for Ambetter from Superior HealthPlan is outlined on their website and through their Member Services phone line. Members can submit complaints in writing, either on paper or electronically, within 180 calendar days of receiving a denial of medical or behavioural health services. Ambetter will acknowledge the complaint within five days and send an oral complaint form for the member to complete and return.
If the complaint is related to claims payment, members must follow the process for claim reconsideration or claim dispute as noted in the Claims section of the Provider Manual. The claim reconsideration process can be initiated by submitting a request through the Secure Provider Portal, calling Provider Services, or mailing a Reconsideration and Claim Dispute Form. This must be done within 180 calendar days from the date of the original Explanation of Payment (EOP) or denial.
If a member is dissatisfied with the complaint resolution, they can request an appeal within 30 days. Ambetter will convene a complaint appeal panel, including Ambetter staff, providers, and members, at a site agreed upon by the complainant. The member may attend the hearing, be represented by someone else, or have a representative accompany them. Ambetter will provide its final decision to the member within 30 days of the appeal request.
It is important to note that Ambetter will never retaliate against a member or provider for filing a complaint or appealing a decision.
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Member complaints and appeals
Ambetter from Superior HealthPlan offers a Complaint/Grievance and Appeals process to ensure that its members' rights are protected. The procedures for filing a complaint, grievance, or appeal are outlined in the Ambetter member's Major Medical Expense Policy.
Filing a Complaint
A complaint can be filed by calling Member Services at 1-877-687-1196 (Relay Texas Relay/TTY 1-800-735-2989). Within five days, the member will receive a complaint acknowledgment letter and an oral complaint form. This form must be completed and returned to Ambetter for the complaint process to proceed. Members can also submit written complaints electronically or on paper.
Ambetter logs and tracks all written complaints it receives. After a thorough investigation, Ambetter will provide a written response to the complainant within thirty calendar days from the date the complaint was received. 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 before filing a Complaint.
Filing an Appeal
If a member is not satisfied with the complaint resolution, they can request an appeal within thirty days. In response, a complaint appeal panel, including Ambetter staff, provider(s), and member(s), will be held at a site where the member normally receives healthcare or another agreed-upon site. The member may attend the hearing, have someone represent them, or have a representative attend with them. The panel will make a recommendation, and Ambetter will provide its final decision to the member within thirty days of the member's complaint appeal request.
Members can also request an appeal within one hundred and eighty calendar days of receiving a denial of medical or behavioral health services. Ambetter will send an appeal decision to the member within one working day for life-threatening, urgent, or inpatient services. The appeal decision will be made by a physician with no previous involvement in the case.
Additional Options
If the member is still dissatisfied with the outcome, they may file a complaint with the Texas Department of Insurance (TDI). Ambetter will never retaliate against a member or a provider for filing a complaint or appealing a decision.
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Claim reconsideration
If you are dissatisfied with an Ambetter insurance payment, there are a few steps you can take to appeal the decision. Firstly, it is important to understand the difference between a complaint and an appeal. A complaint is a written expression of dissatisfaction with Ambetter's policies, procedures, or functions, while an appeal is a request to reconsider the decision made in response to a complaint.
If you wish to submit a complaint, you can do so by calling Member Services at 1-877-687-1196 or by sending a written complaint electronically or on paper to the Ambetter from Superior HealthPlan Complaints Department. Ambetter will send an acknowledgement letter within five days, along with an oral complaint form for you to complete and return. Ambetter will then provide a written response to your complaint within 30 calendar days of receiving it.
If your complaint/grievance is related to claims payment, you must follow the process for claim reconsideration before filing a complaint. Claim reconsideration is the process of requesting a review of the original claim outcome, including the payment amount or denial reason. To submit a claim for reconsideration, you must use the product-specific claim reconsideration form, which can be submitted through the Secure Provider Portal, by calling Provider Services at 1-844-518-9505, or by mailing the form to the address listed on it. It is important to note that claim reconsideration must be submitted within 180 calendar days from the date of the original Explanation of Payment (EOP) or denial.
If you disagree with the outcome of the claim reconsideration, you can then proceed with filing an appeal. An appeal must also be submitted within 180 calendar days from the most recent EOP. In response to your appeal, a complaint appeal panel, including Ambetter staff, providers, and members, will be held at a site where the member normally receives healthcare or another agreed-upon site. You have the right to attend the hearing, have someone represent you, or have a representative attend with you. Ambetter will provide its final decision on the appeal within 30 days of receiving the request.
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Appeal instructions
If you wish to appeal an insurance payment decision made by Ambetter, you must follow the procedures outlined in the Ambetter member's Major Medical Expense Policy. You can also find information on the appeal process on the Ambetter website or by calling Ambetter at 1-877-687-1196 (Relay Texas Relay/TTY 1-800-735-2989).
To begin the appeal process, you must first file a complaint with Ambetter. This can be done by calling Member Services at the number provided above. Within five days, you will receive a complaint acknowledgement letter along with an oral complaint form. You must complete and return this form for Ambetter to proceed with processing your complaint. Written complaints can be sent on paper or electronically to the Ambetter from Superior HealthPlan Complaints Department. Ambetter will log and track all written complaints and provide a written response within thirty calendar days from the date the complaint was received.
If your complaint/grievance is related to claims payment, you 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. You must submit a claim reconsideration within 180 calendar days from the date of the original Explanation of Payment (EOP) or denial. This can be done by submitting a request through the Secure Provider Portal, calling Provider Services at 1-844-518-9505, or mailing a Reconsideration and Claim Dispute Form to the address listed on the form.
If you are not satisfied with the complaint resolution, you can request an appeal of the complaint resolution within thirty days. In response to your request, a complaint appeal panel including Ambetter staff, provider(s), and member(s) will be held at a site where the member normally receives healthcare or another agreed-upon site. You will receive a hearing packet five days before the appeal panel hearing. You may attend the hearing, have someone represent you, or have a representative attend with you. The panel will make a recommendation, and Ambetter will provide its final decision within thirty days of your appeal request. You may also file a complaint with the Texas Department of Insurance (TDI) by mail or electronically.
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Frequently asked questions
If you need to appeal an insurance payment for Ambetter, you must submit a claim for payment with supporting documentation. If the claim is denied, you can request an appeal within 180 calendar days of receipt of the denial.
You can submit a claim by following the instructions on the notification letter. You can also submit a reconsideration request through the Secure Provider Portal, or by calling Provider Services at 1-844-518-9505.
After submitting an appeal, a hearing packet will be sent to you five days before the appeal panel hearing. You may attend the hearing, have someone represent you, or have a representative attend with you. Ambetter will provide a final decision within 30 days of the appeal request.
