New Claims System Update

Prior Authorization Requirements

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Not all services require precertification.

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
  • Referrals and services from noncontracted providers
  • Durable Medical Equipment (DME)*
  • Outpatient IV infusion or injectable medications
  • Prosthetics
  • Certain reconstructive procedures
  • Occupational, speech and physical therapy
  • Referrals outside of the IntegraNet network
  • Requests for noncovered services under the Medicare program
  • Inpatient Admissions
  • LTAC
  • Inpatient Rehabilitation

Examples of services that require the health plan to perform precertification, not IntegraNet:

  • Inpatient mental health services
  • Transplant services
  • Behavioral health partial hospitalization
  • Part D Drugs that require Authorization (also see 20 Prescription Drug Coverage)

Utilization 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, except holidays.

Ensuring Appropriate Services and Coverage

In conjuction wih our health plan partners, IntegraNet Health is committed to covering out 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:

  • Utilization management decisions are based on appropriateness of care, services, and existence coverage.
  • IntegraNet Health does not compensate physicians, providers, or other individuals conducting utilization review for denials of coverage or services.
  • IntegraNet Health does not provide financial incentives for utilization management decision-makers to encourage decisions that result in under-utilization.

Information about the Utilization Management Process

Providers can contact the Clinical Review staff at (281) 447-6800 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 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.


Authorizations are not a guarantee of payment/coverage. The member must be eligible at the time services are provided, and the member may be subject to cost-sharing amounts described in the member's Evidence of Coverage. Benefits, premiums, and/or co-payments may change on January 1st of each year. Please contact the health plan directly for more information.
Practitioners are ensured independence and impartiality when making referral decisions, which will not influence hiring, compensation, termination, promotion, or other similar matters.