Dental Value-Added Services—Superior HealthPlan, Inc.
Learn how the AI-generated research projects were createdOverall Conclusion
Superior HealthPlan, Inc. did not consistently submit dental value-added services encounters with the correct financial arrangement code.
Source Document
Audit Scope
The inspection scope covered the period from September 1, 2022, through August 31, 2023.
Key Findings Summary
Superior used the incorrect financial arrangement code on 1,635 of 16,180 (10 percent) STAR+PLUS dental value-added services encounters; these were coded as payable dental services (financial arrangement code 04) instead of value-added services (financial arrangement code 11), totaling $58,823.
The incorrect encounters may have been carried through to Superior’s Financial Statistical Reports (FSRs) and could affect capitation rates and potential experience rebates.
AI-Assisted
AI Scope Summary
The audit assessed whether Superior HealthPlan, Inc. properly submitted dental value-added services encounters with the correct financial arrangement code during the STAR+PLUS program, evaluated potential impacts on FSR reporting and rate setting, and proposed corrective actions to prevent misreporting in future periods, with management committing to corrective measures by March 2026; future audits should verify that such corrections were implemented and that subsequent FSRs and claims reflect the appropriate FAC code (11).
AI-Generated Insight
This inspection identifies a data integrity control gap in the submission of dental value-added services, where encounters were misclassified with the wrong financial arrangement code. The resulting misreporting could influence FSR data, capitation calculations, and potential rebates. Remediation relies on updated configuration by the dental contractor and ongoing monthly validation of encounter codes.
Audit Objectives
Determine whether Superior HealthPlan, Inc. submitted encounters for dental value-added services in accordance with applicable requirements.
Audit Findings (2)
Superior used the incorrect financial arrangement code on 1,635 of 16,180 (10 percent) STAR+PLUS dental value-added services encounters; these were coded as payable dental services (financial arrangement code 04) instead of value-added services (financial arrangement code 11), totaling $58,823.
The incorrect encounters may have been carried through to Superior’s Financial Statistical Reports (FSRs) and could affect capitation rates and potential experience rebates.
Recommendations (5)
Implement controls to verify it reports STAR+PLUS dental value-added services encounters with the correct financial arrangement code.
Correct the encounters and paid claims submitted with the incorrect financial arrangement code as applicable.
Review its state fiscal year 2023, 2024, and 2025 FSRs to determine whether any reported dental value-added services expenses were included in the medical expenses.
Contact HHSC Financial Reporting and Audit Coordination to receive guidance on the correction of any misreported medical expenses.
Review its state fiscal year 2026 encounters to verify financial arrangement code 11 was used as applicable until a control is implemented.