The provider complaint and appeal procedures are designed to permit IntegraNet to examine issues fully and fairly before completion of the IntegraNet internal review process. Special processes apply to appeals that involve utilization review decisions on clinical benefits. IntegraNet typically determines provider appeals within 60 days (for utilization review cases) or 60 days (for other cases) when sufficient information is received to make a decision.

Medicare Participating Provider Standard Appeal
A formal request for review of a previous IntegraNet decision where medical necessity was not established where provider liability was assigned (see original decision letter) for services already rendered.

Provider Medical Necessity Appeals Responsibility
All requests must be:

• Submitted in writing
• Submitted within 180 days* from the IntegraNet decision letter date
• Include a cover letter with:
• Member identifiable information
• Date(s) of service in question
• Specific rationale as to why the services did in fact meet medical criteria and reference specifics within the medical record to refute the original decision
• Include necessary attachments
• Copy of the original IntegraNet decision
• All applicable medical records

Appeals should be mailed to:
Medicare Complaints, Appeals & Grievances (MCAG)
Attention: Medical Necessity Provider Appeals
2900 North Loop W, Ste 700
Houston, TX 77092

Providing the above information will enable the IntegraNet Participating Provider Appeals team to properly and timely review requests within 60 business days. Requests that do not follow the above may be delayed.

*Days from original denial date may differ, depending upon the contract and/or state requirement

Medicare Participating Provider Administrative Plea/Appeal
A formal request for review of a previous IntegraNet decision where a determination was made that the participating provider failed to follow administrative rules and provider liability was assigned (see original decision letter) where services have already been rendered.

Appeals for failure to provide timely notification will not be reviewed clinically until the late notification denial is resolved. Provider Administrative Plea/Appeals Responsibility:

All request must be:

• Submitted in writing
• Submitted within 180 days* from the IntegraNet decision letter date
• Include a cover letter with:
• Member identifiable information
• Date(s) of service in question
• Specific rationale as to why the administrative rules were not followed and requires an exception to be made or extenuating circumstance that warrants a re-review of the request for provision of payment.
• Include necessary attachments:
• Copy of the original IntegraNet decision
• All applicable medical records

Request should be mailed to:
IntegraNet Health
Attention: Claims Department
2900 North Loop W, Ste 700
Houston, TX 77092

Providing the above information willenable the IntegraNet Participating Provider Appeals team to properly and timely review requests within 60 business days. In the event IntegraNet waives the administrative requirement, the request will be transferred to the appropriate area for review under that process and applicable time frames.

Request that do not follow the above may be delayed.

*Days from original denial date may differ, depending upon the contract and/or state requirement (MMP/DSNP)

Medicare Provider Payment disputes (Claim Re-review)
A formal request from a provider contesting the paid amount on a claim which does not include a medical necessity or/and claims payment determinations have already been rendered.

All payment disputes must be:

• Submitted in writing
• Submitted within 60 days* from the IntegraNet original payment
• Include cover letter with:
• Claim identifiable information
• Specific rationale as to why the payment made is not appropriate or needs adjust
• Include necessary attachments:
• Copy of the original IntegraNet payment (EOP)
• All applicable medical records or other attachments supporting additional payment

Providing the above information will enable the IntegraNet Payment Dispute Unit to properly and timely review requests. Requests that do not follow all the above may be delayed.

*Days from original denial date may differ, depending upon the contract and/or state requirement (MMP/DSNP)