16 INTEGRANET COMPLAINTS, APPEALS, GRIEVANCES AND DISPUTES
16.4 IntegraNet Nonparticipating Provider Appeals Rights
If a claim is partially or fully denied for payment, the nonparticipating provider must request a reconsideration of the denial within 60 calendar days from the remittance notification. When submitting the reconsideration of the denial of payment on a claim, a signed Waiver of Liability form must be included. To obtain this form, please click here.
The purpose of the Waiver of Liability form is to hold the enrollee harmless regardless of the outcome of the appeal.
With the appeal, the nonparticipating provider should include documentation such as a copy of the original
claim, remittance notification showing the denial, and any clinical records and other documentation that
supports the provider's argument for reimbursement. The appeal must be in writing and mailed to:
Grievances and Appeals
2900 North Loop W, Ste 700
Houston, TX 77092
Or filed online at https://inetclaims.zendesk.com
Fax: 832-320-7221