16 INTEGRANET COMPLAINTS, APPEALS, GRIEVANCES AND DISPUTES
16.1 Distinguishing Between IntegraNet, Health Plan, Provider and Medicare Advantage Member
Complaints, Appeals and Grievances
There are separate and distinct processes for requests to reconsider an IntegraNet decision on an
authorization or request for payment upon claims submission. On processing each request, assignment of
liability for the service is determined.
All Medicare member liability denials are subject to the Medicare Complaint, Appeal & Grievance (MCAG) process as outlined in the member appeals and grievances section. Disputes between the health plan and the provider that do not involve an adverse determination or liability for the Medicare member would follow the IntegraNet participating provider appeals and dispute or nonparticipating provider payment dispute processes.
Providers must cooperate with IntegraNet and with members in providing necessary information to resolve the appeals within the required time frames. Providers must provide the pertinent medical records and any other relevant information upon request and when initiating an appeal. In some instances, providers must provide the records and information very quickly in order to allow IntegraNet to make an expedited decision. Your participation in, along with the member’s election of the Medicare Advantage plan, are an indication of consent to release those records as part of the health care operations.
Medicare Member Liability — IntegraNet has determined that a Medicare member is responsible for payment as the service(s) are determined to be not covered under the plan to which they are enrolled or is considered Medicare member cost-share. Any time a member liability denial letter is issued, the member appeals process should be followed and not the provider appeals process. Medicare member liability is assigned when:
- The Integrated Denial Notice (IDN) is issued as per the Medicare Managed Care Manual, Chapter 13: Appeal rights with subsequent review by the Independent Review Entity (IRE).
- Notice of Medicare Non-Coverage (NOMNC) is issued as per the Medicare Managed Care Manual, Chapter 13: Appeal rights with rights to pursue an appeal via the Quality Improvement Organization (QIO) or the plan directly.
- An Explanation of Benefits (EOB) indicates there is member responsibility assigned to a claim processed.
Members that are dually eligible, either as full benefit dual eligible or as part of a Medicare Savings Program, are protected from liability of Medicare premiums, deductible, coinsurance and copayment amounts. This includes cost share being applied to this/these claims. Providers may not bill a dual eligible that has this coverage for any balance left unpaid (after submission to Medicare, a Medicare carrier and subsequently Medicaid) as specified in the Balanced Budget Act of 1997. Providers that service dual-eligible beneficiaries must accept the amounts paid by Medicare as payments in full, as well as any payment under the state Medicaid processing guidelines. Providers who balance bill the dual eligible beneficiary are in violation of these regulations and are subject to sanctions. Providers also may not accept dual eligible beneficiaries as ‘private pay’ in order to bill the patient directly and providers identified as continuing to bill dual eligible beneficiaries inappropriately will be reported to CMS for further action/investigation.
Participating Provider Liability — IntegraNet has determined that the participating provider has failed to follow the terms and conditions of their contract either administratively or by not providing the clinical information needed to substantiate the services being requested for approval of payment. Participating providers are prohibited from billing a Medicare member for services unless the health plan has determined member liability and issued the appropriate notices as above.
Nonparticipating Provider Liability — IntegraNet has determined that the nonparticipating provider with the plan has failed to follow Medicare processing guidelines nonparticipating providers are prohibited from billing a Medicare member for services unless the plan has determined member liability and issued the appropriate notices as above and has procedures for nonparticipating provider to follow.