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

Utilization 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, except holidays.

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 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.

Language Assistance

If you speak any language other than English, and need assistance with an authorization, language assistance services are available to you, free of charge. Call our Utilization Management Department at (281) 591-5289 or (888) 292-1923, TTY users 521 or (800) 982-1448.

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 (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 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 opportunity to discuss the plan of treatment and the clinical basis for the decision, prior to final determination.

The discussion does not represent an appeal.

For assistance, contact the Utilization Services at (281) 591-5289 or 888-292-1923

Disclaimer

Authorizations are not a guarantee of payment/coverage. The member must be eligible at the time services are provided, and the member may be subject to cost-sharing amounts described in the member’s Evidence of Coverage. Benefits, premiums, and/or co-payments may change on January 1 of each year. Please contact the health plan directly for more information.

Lasted updated 6/22/2022