An appeal refers to any of the procedures that deal with a request to review a denial of payment or services. If a member believes he or she is entitled to receive a certain service and IntegraNet denies it, the member has the right to appeal the decision. It is important to follow the directions in the denial letter issued to ensure the proper appeals process is followed.

A member may appeal:

• An adverse initial organization determination by IntegraNet or a provider concerning authorization for or termination of coverage of a health care service
• An adverse initial organization determination by IntegraNet concerning reimbursement for a health care service
• An adverse initial organization determination by IntegraNet concerning a refusal to reimburse for a health service already received if the refusal would result in the member being financially liable for the service
• An adverse coverage determination by IntegraNet or a provider concerning authorization for prescription drugs

Appeals should be sent to:
Medicare Complaints, Appeals & Grievances
Attention: Member Appeals Unit
2900 North Loop W, Ste 700
Houston, TX 77092

Fax: 281-447-6802

All Medicare member concerns that do not involve an initial determination are considered grievances and are addressed through the grievance process.

Participating Provider Responsibilities in the Medicare Member Appeals Process

• Physicians can request standard service or expedited appeals on behalf of their members; however, if not requested specifically by the attending, an Appointment of Representative Form to submit an appeal on behalf of a Medicare member, may be required. The Appointment of Representative Form can be found online and downloaded at www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.
• When submitting an appeal, provide all medical records and/or documentation to support the appeal at that time. Please note that if additional information is requested, it will delay processing of the appeal
• Expedited appeals should only be requested if the normal time period for an appeal could jeopardize the member’s life, health or ability to regain maximum function.
• The CMS guidelines should be used when requesting services and initiating the appeals process Appeal time frames
• Members or their authorized representatives have 60 days from the date of the denial of service to file an appeal. The 60-day filing deadline may be extended if good cause can be shown.
• For standard service appeals, service and payment issues must be resolved within 30 calendar days from the date the request was received.
• If the normal time period for an appeal could jeopardize the member’s life, health or ability to regain maximum function, a request for an expedited appeal are may be submitted orally or in writing. Such appeals generally resolved within 72 hours, unless it is in the member’s interest to extend this time period.
• For payment appeals, service and payment issues must be resolved within 60 calendar days from the date the request was received. All payment appeals must be submitted in writing.