IntegraNet is delegated Utilization Management for the Amerivantage population of our Primary Care Physicians.

Authorization/Referral request may be submitted online at   www.inetDr.com

For an optimal experience with the portal Google Chrome is recommended.  It is also recommended to clear the cache on a regular basis (browsing history).

To request access to  our portal, please complete the Portal Submission Request Form.

     Fax the form to 281-405-3431

Click Here  for a step by step user guide for the portal on how to enter a request.

 For assistance with the Provider Portal, contact the UM department at (281) 591-5289  or  888-292-1923

Utilization Management Decisions

Physician and nurse reviewers at IntegraNet Health use written criteria to assist in the determination of medical necessity.  The following medical necessity criteria are used and available to contracted physicians and providers upon request:

•              Centers for Medicare & Medicaid (CMS) National Coverage Determination (NCD)

•              CMS Local Coverage Determination (LCD), when applicable

•              For drugs and biologics, Medicare approved Drug Compendia

•              Health Plan Clinical UM Guidelines and Behavioral Health UM Guidelines, when applicable

•              AIM Specialty Health Guidelines for diagnostic imaging and sleep studies

•              MCG (formally called Milliman Care Guidelines) if there are no existing Medicare policies available

A contracted physician or provider can request criteria related to a specific medical decision for a patient by calling Utilization Services at 281-591-5289 or 888-292-1923 during normal business hours 8:00 a.m. to 5:00 p.m. Monday - Friday, that is not a legal holiday.

Precertification

Certain services/procedures require precertification from IntegraNet for participating and nonparticipating PCPs and specialist.  Please refer to the list below or for Amerigroup specific codes to determine if precertification is needed (or not) use the Precertification Lookup tool online @https://providers.amerigroup.com/Pages/PLUTO.aspx or call our Utilization Services at 281-591-5289 for more information.

The following are examples of services requiring precertification before providing the following nonemergent or urgent care services:

  • Skilled Nursing Facility (SNF)
  • Home health care
  • Diagnostic tests, including but not limited to MRI, MRA, PET scans, etc. 
  • Hospital or ambulatory care center-based outpatient surgeries for certain procedures
  • Elective inpatient admissions
  • Referrals and services from noncontracted providers
  • Durable Medical Equipment (DME)*
  • Outpatient IV infusion or injectable medications
  • Prosthetics
  • Certain reconstructive procedures
  • Occupational, speech and physical therapy services
  • Referrals outside of the IntegraNet network
  • Requests for noncovered services under the Medicare program
  • Inpatient Admissions
  • LTAC
  • Inpatient Rehabilitation

 

The following are examples of services that require precertification from the health plan, not IntegraNet:

  • Inpatient mental health services
  • Transplant evaluation and services
  • Behavioral health partial hospitalization
  • Part D Drugs that require Authorization (also see 20 Prescription Drug Coverage)

Information about the Utilization Management Process

Providers can contact the Clinical Review staff at (281) 591-5289 or (888) 292-1923, during normal business hours, Monday-Friday, 8:00 a.m. to 5:00 p.m., Central Time to discuss specific Utilization Management requirements/procedures or the UM process.  Calls are answered in the order in which they are received by a non-clinical operator and routed appropriately.

Ensuring Appropriate Service and Coverage

In conjunction with our health plan partners, IntegraNet Health is committed to covering our mutual plan members’ care and encourage appropriate use of healthcare services.  Physicians, providers and IntegraNet staff who make utilization-related decisions must comply with the following policies:

  • Utilization management decisions are based on appropriateness of care and services and existence coverage.
  • IntegraNet Health does not compensate physicians, providers, or other individuals conducting utilization review for denials of coverage or services.
  • IntegraNet Health does not provide financial incentives for utilization management decision-makers to encourage decisions that result in under-utilization.

Medical Director Calls (also called Peer-to-Peer)

The IntegraNet Health Medical Director will review cases where the potential for denial is raised during the pre-authorization review process.  In any instances where the medical necessity or appropriateness of the requested service is questioned by the Utilization Review Coordinator, or Health Plan, the UM Medical Director will make a reasonable effort to contact the requesting and/or attending provider to afford them the