If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate clinical professionals.

IntegraNet will make every effort to resolve the claim payment appeal 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 mail you a written extension letter before the expiration of the initial 30 calendar days.

The claim payment appeal determination letter will include:

• 1.      A statement of the provider's claim payment appeal 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.      A statement about how to submit a state fair hearing.

If the decision results in a claim adjustment, the payment and EOP will be sent separately.

Appeals submission by mail:

IntegraNet Health Attn: Claims
2900 North Loop West, #700
Houston, TX 77092

Submission via web: IntegraNet Provider Portal
Submission by phone (Verbal): (832) 320-7220
Submission by Fax: (832) 320-7221

*Appeals form must be filled out and submitted with any supporting documentation for review.

There are two steps in the internal complaint process:

• Initial Review
• Second-Level Review

The first level in the appeals process
Which involves a review of an adverse organization determination by IntegraNet Health, the evidence and findings upon which it was based, and any other evidence submitted by a party to the organization determination, the MA plan or CMS.

The second level in the appeals process
Which involves a review of an adverse coverage determination by an independent review entity (IRE), the evidence and findings upon which it was based, and any other evidence the provider submits, or the IRE obtains. As used in this guidance, the term may refer to the first level in the Part C appeals process in which the MA plan reviews an adverse Part C organization determination or the second level of appeal in both the Part C appeals process in which an independent review entity reviews an adverse plan decision.

Initial Review

1.     Complaints may be verbal or in writing. The request should indicate the remedy or corrective action being sought. For          example, a complaint may deal with a claim denial, and the remedy being sought is payment of the claim.

2.   IntegraNet Health acknowledges the reconsideration and determines if there is further documentation needed. If          additional information is needed the provider will be contacted to obtain additional documentation.

3.    The Initial Complaint Review Committee investigates the complaint. The committee, which consists of one or more     IntegraNet Health employees who were not involved in a prior decision to deny the claim, investigates the          reconsideration.

4.   The committee decides and notifies the provider. The committee makes a decision within 30 calendar days of      receiving a complaint. The provider will be notified within five business days of the committee’s decision. The           notification states the reason for the decision and the providers appeal rights.

If a provider accepts the decision of the Initial Complaint Review Committee, no further action is required; however, if the provider appeals the decision, the complaint procedures continue with the Second-Level Review.

Second-Level Review

1.      Provider appeals the decision of the Initial Review Committee (Level one reconsideration).

2.    Within 60 calendar days of the decision of the Initial Complaint Review Committee, a provider may file an appeal in        writing to IntegraNet Health Second-Level Review Committee. This committee consists of three or more people who         did not participate in the matter under review.

3.     IntegraNet Health acknowledges the appeal and begins to process.

4.     IntegraNet Health conducts a Second-Level Review Committee meeting. The committee makes a decision based upon         the Second-Level Review Committee hearing.

5.    Second-Level Review Committee makes a decision. The Second-Level Review Committee issues a written notification        within five business days of making its decision, specifying its reasons. The decision letter includes information about         how to file a complaint with a government agency.