8.4 Medically Necessary Services and Medical Criteria

New Claims System Update

Provider Manual

8 Health Care Management Services

8.4 Medically Necessary Services and Medical Criteria

IntegraNet requires precertification for coverage of selected nonemergent outpatient and ancillary services. Requests for precertification with all supporting documentation should be submitted immediately upon identifying the need for the request (14 days’ advance notification for standard requests and three days’ advance for expedited)

To ensure timeliness of the decision, the following must be provided:

Member name and ID number

Name, telephone number and fax number of provider/physician performing the elective service

Name of the facility and telephone number where the service is to be performed

Date of service

Member diagnosis

Name of elective procedure to be performed with CPT code

Medical information to support requested services (medical information includes current signs/symptoms, past and current treatment plans, response to treatment plans and medications)