14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.6 Provider Obligations - Precertification
Providers are responsible for obtaining precertification from IntegraNet before performing certain procedures, when rendering noncovered services or when referring members to noncontracted providers. Please refer to the Summary of Benefits document for those procedures that require precertification or call Provider Services at the DSU at 1-866-805-4589. IntegraNet will render a determination on the request within the appropriate time frame and provide notification of the decision. Requests that are denied will generate a notice that includes the denial rationale and applicable appeal rights. Medicare members will receive a denial letter as well that includes appeal rights. Denials that are the result of contractual issues between IntegraNet and the provider will not generate a member denial letter.
- An initial organization determination is any determination (e.g., an approval or denial) made by IntegraNet for coverage of medical services (Part B-covered services).
- An initial coverage determination is any determination (e.g., an approval or denial) made by IntegraNet for coverage of prescription drugs (Part D-covered services).
When IntegraNet Health processes a coverage request that involves a prior authorization (PA) or other utilization management (UM) requirement, such as step therapy for IntegraNet Health determination on whether to grant approval of a service for a provider constitutes an initial determination and is subject to appeal. In addition, if IntegraNet Health denies coverage of a service 28 or a because the provider failed to seek PA or failed to comply with similar limits on coverage, the denial also constitutes an initial determination and is subject to appeal.
Thus, the adjudication timeframe, notice, and other requirements applicable to coverage determinations or organization determinations under, subpart apply to requests that involve a PA or other UM requirement in the same manner that they apply to all coverage requests. If a provider requests coverage of a service, item, or drug that involves PA, the plan must accept and process the request as a coverage determination or organization determination and should contact the physician or prescriber for information needed to satisfy the PA, in accordance with the outreach guidance at IntegraNet Health.