IntegraNet is delegated Utilization Management for the Amerivantage population of our Primary Care Physicians.
Authorization/Referral request may be submitted online at www.inetDr.com
To request access to our portal, please complete the Portal Submission Request Form.
Fax the form to 281-405-3431.
Click Here for a step by step user guide for the portal on how to enter a request.
For assistance with the Provider Portal, contact the UM department at 281-591-5289 or 888-292-1923
Utilization Management Decisions
Physician and nurse reviewers at IntegraNet Health use written criteria to assist in the determination of medical necessity. The following medical necessity criteria are used and available to contracted physicians and providers upon request:
• Centers for Medicare & Medicaid (CMS) National Coverage Determination (NCD)
• CMS Local Coverage Determination (LCD), when applicable
• For drugs and biologics, Medicare approved Drug Compendia
• Health Plan Clinical UM Guidelines and Behavioral Health UM Guidelines, when applicable
• AIM Specialty Health Guidelines for diagnostic imaging and sleep studies
• MCG (formally called Milliman Care Guidelines) if there are no existing Medicare policies available
A contracted physician or provider can request criteria related to a specific medical decision for a patient by calling Utilization Services at 281-591-5289 or 888-292-1923 during normal business hours 8:00 a.m. to 5:00 p.m. Monday - Friday, that is not a legal holiday.
Certain services/procedures require precertification from IntegraNet for participating and nonparticipating PCPs and specialist. Please refer to the list below or for Amerigroup specific codes to determine if precertification is needed (or not) use the Precertification Lookup tool online @https://providers.amerigroup.com/Pages/PLUTO.aspx or call our Utilization Services at 281-591-5289 for more information.
The following are examples of services requiring precertification before providing the following nonemergent or urgent care services:
The following are examples of services that require precertification from the health plan, not IntegraNet:
Information about the Utilization Management Process
Providers can contact the Clinical Review staff at (281)-591-5289 or (888) 292-1923, during normal business hours, Monday-Friday, 8:00 a.m. to 5:00 p.m., Central Time to discuss specific Utilization Management requirements/procedures or the UM process. Calls are answered in the order in which they are received by a non-clinical operator and routed appropriately.
Ensuring Appropriate Service and Coverage
In conjunction with our health plan partners, IntegraNet Health is committed to covering our mutual plan members’ care and encourage appropriate use of healthcare services. Physicians, providers and IntegraNet staff who make utilization-related decisions must comply with the following policies:
Medical Director Calls (also called Peer-to-Peer)
The IntegraNet Health Medical Director will review cases where the potential for denial is raised during the pre-authorization review process. In any instances where the medical necessity or appropriateness of the requested service is questioned by the Utilization Review Coordinator, or Health Plan, the UM Medical Director will make a reasonable effort to contact the requesting and/or attending provider to afford them the the opportunity to discuss the plan of treatment and the clinical basis for the decision, prior to a final determination.