You can also access information concerning precertification requirements and the directory listing of participating providers on our website at www.InetDr.com.

The following are examples of services requiring precertification before providing the following nonemergent or urgent care services:

Skilled Nursing Facility (SNF)

Home health care

Diagnostic tests, including but not limited to MRI, MRA, PET scans, etc.

Hospital or ambulatory care center-based outpatient surgeries for certain procedures

Elective inpatient admissions

Elective inpatient admissions

Durable Medical Equipment (DME)*

Outpatient IV infustion on injectable medications

Prosthetics

Certain reconstructive procedures

Occupational, speech and physical therapy services

Referrals outside of the IntegraNet network

Requests for noncovered services under the Medicare program

Inpatient Admissions

LTAC

Inpatient Rehabilitation

The following are examples of services that require precertification from the health plan, not IntegraNet:

Inpatient mental health services

Transplant evaluation and services

Behavioral health partial hospitalization

Part D Drugs that require Authorization (also see 20 Prescription Drug Coverage)

For services that require prior authorization or are noncovered by the plan (i.e., statutory exclusion), it becomes extremely important that all authorization procedures are followed. If a member elects to receive such care the member cannot be held financially responsible unless notified in advance of the noncovered services. In such cases when the network physician fails to follow authorization protocols, IntegraNet may decline to pay the claim in which case the physicians will be held financially responsible for services received by the member. Again, CMS prohibits holding the member financially responsible in these cases.

A written coverage determination will help ensure that a claim for noncovered care from a contracted provider is paid accurately. According to CMS, if the appropriate written notice of denial of payment is not given to the Medicare Advantage member regarding a noncovered service, the claim may be denied, and the member cannot be held financially responsible. Therefore, your failure to provide an appropriate coverage determination could result in a denial of payment for the noncovered service.

Contact us prior to services being rendered to comply with this requirement and ensure appropriate claims payment and allow you to bill the Medicare member in the event of noncoverage. As a contracted provider with us, you are prevented from billing the Medicare member for any service that is deemed noncovered if you have not ensured this advanced notification has been issued.