Please Fax form to: 281-405-3431
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
- Health Plan Clinical UM Guidelines, when applicable
- MCG (formally called Milliman Care Guidelines)
- Ambulatory Care
- Inpatient & Surgical Care
- General Recovery Care
- Recovery Facility Care
A contracted physician or provider can request criteria related to a specific medical decision for a patient by calling Utilization Management at (888) 292-1923 during normal business hours 8:00 a.m. to 5:00 p.m. Monday - Friday, that is not a legal holiday.
Information about the Utilization Management Process
Providers can contact the Clinical Review staff at (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:
- Utilization management decisions are based on appropriateness of care and 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.
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 opportunity to discuss the plan of treatment and the clinical basis for the decision, prior to final determination.
Please keep in mind the following:
- The discussion does not represent an appeal.
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 1 of each year. Please contact the health plan directly for more information.