New Claims System Update

11.6 Appeals Process

Provider Manual
heartbeat_stet

11 Credentialing

11.6 Appeals Process

Upon a denial, suspension, termination or nonrenewal of a physician’s participation in the provider network, IntegraNet acts as follows:

The affected physician is given a written notice of the reasons for the action, including if relevant, the standards and profiling data used to evaluate the physician and the numbers and mix of physicians needed by IntegraNet. Written communication to the provider details the deficiencies and informs him or her of the right to appeal.

  • The physician is allowed to appeal the action to a hearing panel
  • The physician is provided written notice of the right to a hearing and the process and timing for requesting a hearing
  • IntegraNet ensures the majority of the hearing panel members are peers of the affected physician
  • IntegraNet notifies the NPDB, the appropriate state licensing agency and any other applicable licensing or    disciplinary body to the extent required by law, if a suspension or termination is the result of quality of care       deficiencies

    • IntegraNet’s decisions subject to an appeal include decisions regarding reduction, suspension or termination of a provider’s participation resulting from quality deficiencies. IntegraNet notified the NPDB, the appropriate state licensing agency and any other applicable licensing or disciplinary body to the extent required by law. Written communication to the provider details the deficiencies and informs him or her of the right to an appeal.