IntegraNet accepts reconsideration requests in writing, verbally and through our provider web portal within 120 days from the date of the Explanation of Payment (EOP). Non contracted providers must submit a request for a partially denied or fully denied claim within 60 days from the date on the EOP. A waiver of liability is required for non-contracted provider reconsideration requests. Reconsideration requests not filed in the time frames permitted will be considered untimely and denied unless good cause can be established.

When submitting reconsiderations, please include as much information as you can to help us understand why you think the claim was not paid as you would expect.

Providers are encouraged to use our claims payment reconsideration process if you feel a claim was not processed correctly, however, this optional step is not required prior to filing a claim payment appeal.

If a reconsideration requires clinical expertise, it will be reviewed by appropriate IntegraNet clinical professionals.

IntegraNet will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days.

We will send you our decision in a determination letter when upholding our decision, which will include:

• 1.      A statement of the provider's reconsideration request.
• 2.      A statement of what action the plan intends to take or has taken.
• 3.      The reason for the action.
• 4.    Support for the action including applicable statutes, regulations, policies, claims, codes or provider manual          references.
• 5.    An explanation of the provider’s right to request a claim payment appeal within 180 calendar days of the date         of the reconsideration determination letter.
• 6.    An address to submit the claim payment appeal.

If the decision results in a claim adjustment, the payment and Explanation of Payment (EOP) will be sent separately. Overturned decisions will result in an adjustment and EPOs.