Fillable 1578423405. Portal Submission Request Form

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1578423405. Portal Submission Request Form

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1900 North Loop West
4
th
Floor
Houston, Texas 77018
P: 281.447.6800 F: 281.447.6802
www.IntegraNetHealth.com
800.
994.1388
2730 North Stemmons Frwy
West Tower, Suite 1003
Dallas, Texas 75207
P: 972.677.2696 F: 832.456.2638
Portal Submission Request Form
RE:
CHANGE IN AUTHORIZATION REQUEST PROCESS FOR AMERIVANTAGE – INTEGRANET HEALTH
IntegraNet Health is delegated to perform utilization management services for Amerivantage patients of
IntegraNet Health Primary Care Physicians.
We are excited to announce that providers will now be able to log into the IntegraNet Health Provider
Portal to submit authorization request.
To switch to online requests, please identify a member(s) of your staff who will request authorizations.
Please complete and return the Portal Submission Request Form below and a user name and temporary
password will be created
for the Provider Portal. The user name and password will be emailed to the
person identified on the form. The email will come from noreply@aaneel.com
**NOTE: Should Portal access expire, enter user id and reset password
Upon entry into the Portal, the user will be required to change the password before proceeding any
further. The Portal web address is: www.INETDR.COM
The Portal can be used to submit prior authorization request(s), check authorization status, upload
clinical documents to support the request, download and print determination letters, etc.
A step by step guide to access the portal is available at www.integranethealth.com for review. Please
do not hesitate to contact the Utilization Management or Provider Relations Staff for questions,
comments, etc. Your assistance in this matter is greatly appreciated.
Sincerely,
Utilization Management Department
Pl
ease Print
NPI #:
Provider Name:
Submitter’s Last Name:
Submitter’s First Name:
Email:
Address:
City:
State: Zip:
County:
Phone:
Please fax completed form to: (281) 405-3431 ATTN: UM Department
For assistance with the Provider Portal, contact (281) 591-5289
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Completed 18 July 2020

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