Welcome to your provider manual
Your provider resource.................................................................4
Here to help you......................................................................................4
Changes and updates............................................................................5
New to the Aetna
®
network?................................................................5
Local network information...................................................................5
Provider data demographic .........................................................6
Provider office panel status changes................................................6
Closed panel.............................................................................................6
Provider roster requirements .............................................................6
Delegated Entity requirements...........................................................7
Helpful links ...................................................................................8
Key contacts...................................................................................9
Electronic solutions ....................................................................11
Eligibility and benefits inquiry...........................................................11
Patient cost estimator .........................................................................11
Precertification adds, inquiries and updates................................11
Referral add and inquiry.....................................................................12
Claims submissions..............................................................................12
Claim status transactions...................................................................12
Rules for electronic submission .......................................................12
Electronic funds transfer (EFT) .........................................................12
Online claims Explanation of Benefits (EOB) statements .........12
Electronic remittance advice (ERA)...................................................13
Capitated providers .............................................................................13
Working through clearinghouse vendors: transactions by
vendor
......................................................................................................13
Our products................................................................................13
Aetna Benefits Products booklet.......................................................13
Joining our network ....................................................................13
Radiology accreditation ......................................................................14
Physicians-member communication policy ..................................14
Provider identification numbers ......................................................14
Accessibility standards and participation criteria..........................14
Primary care provider (PCP) responsibilities............................14
Specialty care provider responsibilities.....................................15
Physician-requested member transfer......................................15
Medical clinical policy bulletins...........................................................15
Compliance
.............................................................................................16
Nondiscrimination............................................................................16
Members rights and responsibilities..........................................16
Advance directives and the Patient
Self-Determination Act (PSDA)
.......................................................16
Informed consent.............................................................................17
Verifying member eligibility
and benefits .................................................................................17
How to interpret a member ID card ................................................17
Member identification and verification of eligibility
...................17
Newborn enrollment............................................................................18
Verifying benefits
..................................................................................18
Verifying your network participation .....................................18
Precertification ...........................................................................19
Emergencies.................................................................................19
Medical emergencies...........................................................................19
Follow-up care after emergencies ...................................................19
Claims and billing ........................................................................20
Member billing...................................................................................... 20
Billing members for noncovered
services— consent requirements
............................................. 20
Billing and balance-billing members.......................................... 20
Other billing situations................................................................... 20
Initiating a collection action against a payer ........................... 21
Concierge medicine ........................................................................ 21
Claims information
.............................................................................. 21
Electronic claims submission....................................................... 21
Claims submission tips .................................................................. 21
Disagree with a claim decision?................................................... 21
Claims addresses............................................................................. 21
Clean claims ...................................................................................... 22
Coordination of benefits.................................................................... 22
Birthday rule ..................................................................................... 23
Medicare Secondary Payer........................................................... 23
Medicare and Medicaid dual eligibles ....................................... 23
Medicare and Medicaid relationship ........................................ 23
Aetna Medicare Advantage .......................................................... 23
Medicare Part D plans.................................................................... 23
Working aged.................................................................................... 23
Motor vehicle accident................................................................... 23
Claims payment policy — rebundling ............................................ 24
Overpayment recovery ...................................................................... 24
Audits ........................................................................................... 24
Hospital bill audit ................................................................................. 24
Diagnosis-related group (DRG) audit ............................................. 24
Implant audit ......................................................................................... 24
Prepay audit .......................................................................................... 24
OrthoNet ................................................................................................ 24
Where to send Aetna records .......................................................... 25
Medical records ...........................................................................25
Record keeping..................................................................................... 25
Participating practitioner medical record criteria ................. 25
Organization ..................................................................................... 25
Examination ...................................................................................... 27
Studies
................................................................................................ 27
Communicatio
n................................................................................ 27
Records maintenance and access................................................... 27
Maintenance ..................................................................................... 27
Member record access .................................................................. 27
Privacy practices .................................................................................. 28
Referrals ......................................................................................29
Referral policies.................................................................................... 29
Member’s consent for nonparticipating providers’ referrals.. 29
Referral processes............................................................................... 30
Utilization management ...........................................................30
Overview................................................................................................. 30
Utilization management and standards........................................ 30
How to contact us about utilization management issues........ 31
Utilization review policies .................................................................. 31
How we determine coverage............................................................ 31
Admissions protocol ........................................................................... 32
Notify us of hospital admissions within one business day ...... 32
All-products precertification list ..................................................... 32
Member programs and resources ............................................33
Member programs .............................................................................. 33
Care management........................................................................... 33
Disease management..................................................................... 33
Aetna
®
Healthy Lifestyle Coaching program............................ 33
Aetna
®
Lifestyle and Condition Coaching program ............... 34
Fitness programs for Aetna Medicare Advantage members 34
Women’s health programs............................................................ 34
Member resources .............................................................................. 34
24-hour Nurse Line......................................................................... 34
Institutes of Excellence™ network ........................................ 34
Institutes of Quality
®
designation .......................................... 34
Behavioral health................................................................................. 34
Aetna Depression in Primary Care Program................................ 35
Screening, brief intervention and referral to treatment
(SBIRT) practice..................................................................................... 35
Aetna is the brand name used for products and services provided by one or more of the Aetna group of
companies (Aetna).
2
Behavioral health access standards............................................... 35
Opioid Overdose Risk Screening program ................................... 36
Pharmacy management and drug formulary .........................36
Overview of the Pharmacy Plan Drug List (formulary).............. 36
Commercial plans............................................................................ 36
Aetna Medicare Advantage plans ............................................... 36
CVS Caremark Mail Service Pharmacy™........................................ 37
Aetna Specialty Pharmacy
®
mail-order pharmacy ..................... 37
Pharmacy clinical policy bulletins.................................................... 38
Precertification, step therapy and quantity limits...................... 38
Generic drugs ....................................................................................... 39
Medical exception and precertification ........................................ 39
Performance programs ............................................................. 40
Quality, accreditation, review and reporting activities......... 40
Aexcel
®
network of specialist doctors ....................................... 40
Patient-centered medical home (PCMH) .................................. 40
Physician pay for performance (P4P)..........................................41
Clinical medical management ..................................................41
Clinical practice and preventive service guidelines ....................41
Clinical practice guidelines................................................................ 42
Behavioral health clinical practice guidelines.............................. 42
Preventive services guidelines......................................................... 42
Case management............................................................................... 42
Coordination of care .................................................................. 43
Importance of collaboration............................................................. 43
Sharing patient information.............................................................. 43
Accessing communication forms .................................................... 43
Transition of care ................................................................................. 43
The four steps for requesting transition of care .................... 44
Complaints and appeals............................................................ 44
Medicare...................................................................................... 45
Aetna Medicare Advantage plans.................................................... 45
Aetna Medicare Advantage plans (HMO and PPO)................ 45
Home assessment program......................................................... 46
Quality improvement program.................................................... 46
Medicare prescription drug plan ................................................ 46
Transition-of-coverage (TOC) policy........................................... 46
Additional prescription drug plan information....................... 47
Preferred pharmacies .................................................................... 48
Part D drug rules ............................................................................. 48
Home infusion.................................................................................. 48
Additional Aetna Medicare Advantage information................... 49
Physician–member communications policy .............................. 49
Demographic data quarterly attestation
................................. 49
Collecting all Aetna Medicare Advantage plan member
cost sharing
....................................................................................... 49
Access to facilities and records ................................................... 49
Access to services ........................................................................... 50
Medicare Outpatient Observation Notice
(MOON) requirement
..................................................................... 50
Medicare Medical Loss Ratio (MLR) requirements ................ 50
Advance directives .......................................................................... 50
MA Organization Determination (OD) process ........................51
Ban of Advance Beneficiary Notice of Noncoverage (ABN)
for Medicare Advantage (MA)
.......................................................51
Medicare prescription drug plan (PDP and MA-PD)
coverage determinations and exceptions process
................ 52
Exceptions process......................................................................... 52
Medicare Advantage (MA and MA-PD) and Medicare PDP
member grievance and appeal rights
....................................... 52
Obligation to respond to requests for records....................... 53
Confidentiality and accuracy of member records.................. 53
Coverage of renal dialysis services for Medicare members
who are temporarily out-of-area
................................................. 53
Direct access to in-network women’s health specialists ..... 53
Direct-access immunizations ....................................................... 53
Emergency services........................................................................ 54
Health-risk assessment ................................................................. 54
Receipt of federal funds, compliance with federal laws and
prohibition on discrimination
...................................................... 54
Provider terminations .................................................................... 54
Financial liability for payment for services............................... 54
Medicare Compliance Program requirements........................ 55
Standards of Conduct and Compliance policies..................... 55
Exclusion list screening.................................................................. 55
Oversight of your subcontractors .............................................. 56
What may happen if you don’t comply...................................... 56
Making sure you maintain documentation .............................. 56
Annual attestation........................................................................... 56
Report concerns or questions
..................................................... 56
Medicare Access and CHIP Reauthorization Act (MACRA)
reimbursement policy
.................................................................... 56
Temporary move out of the service area ................................. 57
Travel programs — when members are away from home
for an extended period
.................................................................. 57
Travel Advantage (HMO plans)..................................................... 57
Urgently needed services ............................................................. 58
Physicians and other health care professionals and
marketing of Aetna Medicare Advantage plans
...................... 58
Annual notice of change................................................................ 58
Services received under private contract ................................ 59
Claims and billing requirements ................................................. 59
Submitting Medicare claims and encounter data for risk
adjustment
........................................................................................ 59
Risk adjustment medical record validation.............................. 59
Providers of hospice-related services ....................................... 59
Centers for M
edicare & Medicaid Services (CMS) physician
incentive plan: general requirements
........................................ 60
CMS physician incentive plan: substantial
financial risk
...................................................................................... 60
CMS physician incentive plan: stop-loss protection
requirements
.....................................................................................61
Aetna Medicare Advantage organization (MAO)
obligations
..........................................................................................61
Permissible activities.......................................................................61
What contracted providers may do ............................................61
Ambulance services.........................................................................61
Rights and responsibilities for Aetna Medicare Advantage HMO
and PPO plan members with a prescription drug benefit
..... 62
Rights and responsibilities for Aetna Medicare Advantage HMO
and PPO plan members without a prescription drug benefit ... 63
Physician–member communications policy ............................... 65
About Coventry..................................................................................... 66
Workers’ compensation
..................................................................... 66
Contact information and links.......................................................... 66
Workers’ compensation tool............................................................. 66
Injured worker and client identification ........................................ 66
Referral process ................................................................................... 66
Claims administration information................................................. 67
Provider responsibilities .................................................................... 67
Participants in the Coventry Integrated Network....................... 67
Credentialing
......................................................................................... 68
Billing ....................................................................................................... 68
State-specific requirements ............................................................. 68
Coventry Auto Solutions .................................................................... 68
Contact information and links.......................................................... 68
Client identification ............................................................................. 68
Claims administration information................................................. 68
Provider responsibilities .................................................................... 69
First Health
®
and Cofinity
®
networks .......................................69
About First Health and Cofinity ....................................................... 69
Our provider portal ............................................................................ 69
3
Your provider resource
You’ve told us what’s important to you. And we listened.
Through your feedback, we continually update this
manual to make it easier for you to work with us.
This manual applies to any health care provider, including
physicians, health care professionals, hospitals, facilities
and ancillary providers, except when indicated otherwise.
It includes policies and procedures. Aetna may add,
delete or change policies and procedures, including
those described in this manual, at any time. Please read
this manual carefully. Your agreement requires you to
comply with Aetna policies and procedures including
those contained in this manual.
Visit Aetna.com or our provider portal, Availity.com,
to find additional policies, procedures and information.
You’ll find programs we offer that could benefit your
Aetna patients. Plus, electronic transaction tools that
save you time. And of course, you’ll find our contact
information, so you can reach us whenever you need to.
You’ll also find information on how to get your claims paid
faster, your pre-authorization requests processed
promptly, and your administrative burdens lessened.
We want you to find what you need, quickly and efficiently.
Have questions? Contact us via
Aetna.com — we’re here to help.
Creating a diverse, equitable and safe workplace
We are an equal opportunity employer. We believe in
and promote a diverse, equitable and safe workplace
environment. We count on you to do the same in your
hiring practices and workplace policies.
Here to help you
This manual is for you — the physicians, the hospital and
facility staffs, and the providers who participate in our
network and care for our members. It aims to:
• Help you understand our processes and procedures
• Serve as a resource for answering your questions about
our products, programs, or doing business with us
You’ll find almost everything you need to do business
with us. Go to Aetna.com to find other policies and
procedures that are not documented in this manual.
A word about compliance
The policies and information stated in this manual should
align with the terms of your agreement with us. If they
don’t, the terms of your agreement override this manual.
You’re responsible for complying with all applicable laws
and regulations. We may issue notifications regarding
legal requirements as laws or regulations change.
However, you’re responsible for compliance regardless
of whether we’ve issued a notification.
State or federal laws, regulations or guidance may include
requirements that this manual doesn’t mention. In that
event, those requirements apply to you and/or to us. If
those requirements are not consistent with — or are
more stringent than our policies and procedures — they
may override the policies and procedures in this manual.
4
Changes and updates
When things change, we’ll let you know
If you provide us with your email address, we can contact
you with important information, such as updates about
our members and group health plans. Likewise, we
update this manual annually and as needed. When we
make changes that affect you, such as to clinical policies,
procedures, plan names or ID cards, we’ll let you know.
We’ll notify you either by mail, by email or by OfficeLink
Updates
TM
, our provider newsletter. If your office hasn’t
heard from us or your contact information has changed,
let us know.
Our newsletter is published quarterly — March 1, June 1,
September 1 and December 1. It can include changes to
policies that may affect your practice or facility.
Note: OfficeLink Updates is available via email and on
Aetna.com, in the “Providers” section.
New to the Aetna
®
network?
We have tools and resources to help you work with us.
• Aetna at a Glance: this quick reference guide will help
you learn about various tools and transactions. It also
has key contact information.
• Aetna Benefits Products booklet: this handbook
contains information on Aetna benefits products. It
includes primary care physician (PCP) selection, referral
requirements and precertification instructions. To find
these tools, just go to Provider Manuals.
• Provider portal: you’ll notice the term
“provider portal” used throughout this manual. You
can perform most electronic transactions through this
website. That includes submitting professional and
institutional claims, checking patient benefits and
eligibility, requesting precertifications, making edits to
existing authorizations and submitting clinical
information. You must register to use the website. Just
go to Availity.com, select “Register” and then follow the
instructions.
Webinars: on our provider site, you can sign up for
webinars and learn how to work with us.
Local network information
Regulations and Aetna program requirements will vary
from state to state. You can find regional information
in our regional manual supplements which are available
in our online Provider Manuals. They include some
market-specific information and provide access to
important contacts, including website addresses,
telephone and fax numbers.
Note: The term “precertification” (used here and throughout the office manual) refers to the utilization review process
used to determine if a requested service, procedure, prescription drug or medical device meets our clinical criteria for
coverage. It does not mean precertification as defined by Texas law. Texas law defines precertification as a reliable
representation of payment of care or services to fully insured health maintenance organization (HMO) and preferred
provider organization (PPO) members.
5
Provider data demographic
It is important for you and Aetna to keep your information
current and to periodically confirm its accuracy upon
request. We may need to take corrective action if you
don’t notify us of your changes (e.g., changes in notice
address, location, staff and demographics) within a
reasonable time frame.
Provider office panel status changes
Use the following steps to change your office’s
enrollment status.
• Send a letter to your local Aetna office notifying us of
your request. For the mailing address, call your local
Aetna office or 1-800-872-3862 (TTY: 711). There are
two exceptions to this rule:
• In Oklahoma and Texas, mail correspondence
or call our Provider Contact Center at
1-800-624-0756 (TTY: 711).
• In Connecticut, Massachusetts, Maine, New Hampshire,
New York, northern New Jersey,
Rhode Island and Vermont, contact the Provider
Contact Center at 1-800-624-0756 (TTY: 711).
• Indicate the status you are requesting for your office.
- Open: Your office is open and accepting all Aetna
memb
ers.
- Accepting current patients only: Your office is not
accepting any new Aetna members unless the
member is currently a patient in your practice.
- Frozen: Your office is not accepting any new Aetna
members as patients even if the patient is currently a
patient in your practice under another type of
coverage. (“Frozen” status does not apply to primary
care offices in Connecticut, Massachusetts, Maine,
New Hampshire, New Jersey, New York, Rhode Island
and Vermont.)
Closed panel
A broad selection of physicians is important to our
members. And they expect the physicians listed in our
directories to be available. Therefore, we require:
• 90-day advance written notice of a change in the
enrollment status of an office
• That if you decline to accept new members as patients,
you won’t accept additional members from any insurer,
entity or organization which competes with us
Provider roster requirements
This section outlines the standards and requirements
for any provider that submits a roster of providers to
us for loading into our systems. This includes our online
provider search tool.
Delegated Entity
“Delegated Entity” or “Delegate” is a hospital, group
practice, credentials verification organization (CVO) or
other entity that we have given the authority to perform
specific functions. These include credentialing, claims
handling, medical management or other clinical and
administrative functions.
When these responsibilities are delegated to you, you
are known as the “Delegated Entity.” A Delegated Entity
must be compliant with our policies and continue to
maintain compliance. Should we find that a Delegated
Entity is noncompliant with the standards (as laid out
below), the Delegated Entity risks its delegated status
and we may revoke any or all delegated activities.
The information contained on rosters directly impacts
our provider directories and other systems and must be
accurate, updated and complete before we will accept
the roster. We will analyze and score each roster received
and will return poor-quality rosters with an explanation.
We expect the errors to be corrected and the roster sent
back to us.
Continued submission of incorrect roster information
may result in:
• Our refusal to accept any further rosters from your group
• Potential termination of delegate status
• A requirement for your group to directly attest to your
data on a quarterly basis through one of our vendors
• Financial penalties if your group remains noncompliant
Noncompliance will be measured based on vendor
attestations. We will provide several warnings and
opportunities to rectify noncompliant status.
6
Delegated Entity requirements
1. Delegates or other groups who are approved by
us to submit rosters are required to submit a
complete and accurate roster in Excel or similar
format. Word and PDF files are not acceptable.
Examples of roster fields are listed in number 2.
a. Approved provider groups and entities will
submit to us:
• A monthly roster with adds, changes and
deletions
• A quarterly roster that includes all providers
b. We’ll ask approved provider groups and entities
to correct rosters we returned because:
• We could not intake and process them
• They contain formatting issues
c. Approved provider groups and entities are
required to contact each provider in their
network at least once a quarter to validate
that their demographic information is correct.
d. We will measure the quality of the roster.
Rosters determined to be of low quality
(incorrect information or missing information
or using an unacceptable format) will be
returned to the provider group or entity.
e. In the event of noncompliance, we may take
action. This action may include but not be
limited to:
• A request for corrective action plans
• Omission of providers from the search tool
• Our refusal to accept any future rosters from
the provider group or entity
2. Roster fields
The roster shall contain separated fields for each
element. This includes but is not limited to the
following elements:
• Tax ID number
• Tax ID owner name
• Provider last name
• Provider first name
• Provider middle initial
• National Provider Identifier (NPI) number
• NPI type
• Specialty
• Medicare number
• Medicare expiration date
• U.S. Drug Enforcement Administration (DEA)
registration number
• DEA registration number expiration date
• State license number
• State of issue
• State license expiration date
• Service location street address
• Service location city
• Service location state
• Service location ZIP code
• Service location appointment phone number
• Service location fax number
• Service location email
• Accepting new patients (Y or N)
• Languages spoken by staff
• Office hours
• Accessible to persons with disabilities
• Age treated
• Gender treated
• Billing location street address
• Billing location city
• Billing location state
• Billing location ZIP code
7
Helpful links
Here are the websites to use to access related content and information.
Website Link
Aetna Aetna.com
Aetna Compassionate Care
SM
program AetnaCompassionateCare.com
Aetna Medicare AetnaMedicare.com
The Aetna medication search tool (formulary) Aetna.com/fse/plantypedo?businesssectorcode=CM
The Aetna provider portal Availity.com
Aetna Signature Administrators
®
Aetna.com/healthcare-professionals/documents-
forms/aetna-signature-administrators.pdf
The Aetna site for health care professionals Aetna.com/health-care-professionals.html
Aetna Women’s Health
SM
program WomensHealth.Aetna.com
CAQH
®
CAQH.org
Coventry CoventryProvider.com
Coventry Auto Solutions CoventryAutoSolutions.com
Coventry Health Care Workers Compensation, Inc. CoventryWCS.com/content/Menu/Home/Providers.
html
Drug formularies Aetna.com/health-care-professionals/clinical-
policy-bulletins/pharmacy-clinical-policy-
bulletins.html
First Health and Cofinity ProviderLocator.firsthealth.com/home/index
Harvard Health Health.Harvard.edu
Online referral search tool Aetna.com/docfind
8
Key contacts
Here are the numbers to call for questions or requests on behalf of your patients.
Department Contact information
Provider Contact Center
• Member eligibility and benefits
• Claim inquiries and questions
• Patient management
• Precertification
For HMO-based and Aetna Medicare Advantage plans:
1-800-624-0756 (TTY: 711)
For all other plans:
1-888-MD-Aetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
Aetna Credentialing Customer Service Department 1-800-353-1232 (TTY: 711)
Aetna Health Connections
SM
Disease Management
program
1-866-269-4500
(TTY: 711)
Aetna Signature Administrators
®
Refer to the member ID card.
Aetna Specialty Pharmacy
®
self-injectable medication
mail order
Phone: 1-866-782-2779
(TTY: 711)
Visit our website.
Aetna Student Health
SM
plans Visit our website.
Aetna Voluntary Plans and Limited Benefits Insurance
Plan (formerly “Aetna Affordable Health Choices”)
1-888-772-9682 (TTY: 711)
Aetna Maternity Program 1-800-272-3531 (TTY: 711)
Behavioral health (member services) 1-888-632-3862 (TTY: 711)
Behavioral health (provider services) Refer to the member ID card.
Breast Health Education Program 1-888-322-8742 (TTY: 711)
BRCA Genetic Testing program
(genetic testing for breast and ovarian cancers)
1-877-794-8720
(TTY: 711)
Coventry Auto Solutions 1-800-937-6824
(TTY: 711)
Coventry Health Care Workers Compensation, Inc 1-800-937-6824
(TTY: 711)
CVS Caremark Mail Service Pharmacy™ • Phone: 1-888-792-3862 (TTY:711)
• Fax: 1-800-378-0323
9
Department Contact information
Dispute submission
Write to the PO box listed on the Explanation of
Benefits (EOB) statement or the denial letter related to
the issue you’re disputing. Include the reason(s) for the
disagreement.
HMO-based and Aetna Medicare Advantage plans:
1-800-624-0756 (TTY: 711)
All other plans: 1 -888-MD-Aetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
Note: When you call, have the EOB statement and the
original claim handy.
Enhanced clinical review program CareCore National (doing business as “eviCore
healthcare”)
1-800-420-3471
Medsolutions (doing business as “eviCore
healthcare”)
1-888-693-3211
National Imaging Associates (NIA)
1-866-842-1542
Infertility program 1-800-575-5999 (TTY: 711)
24-hour Nurse Line 1-800-556-1555 (TTY: 711)
Medicare expedited organization determinations (EODs) Fax: 1-860-754-5468
Note: Use this fax number only for Medicare EODs.
Continue using your current process for:
• All requests that are not expedited
• All requests for Part B medical injectable items
National Medical Excellence Program
®
(transplants) 1-877-212-8811
(TTY: 711)
Pharmacy management precertification Commercial plans:
• Phone: 1-855-240-0535
(TTY: 711)
• Fax: 1-877-269-9916
Medicare Part D pharmacy management
precertification:
• Phone: 1-800-414-2386
(TTY: 711)
• Fax: 1-800-408-2386
Specialty drug precertification:
• Phone: 1-866-503-0857
(TTY: 711)
• Fax: 1-888-267-3277
• Medicare Part B fax: 1-844-268-7263
• Website: Availity.com
SilverScript
®
Part D plan • Phone: 1-866-235-5660
• Fax: 1-855-633-7673
10
Electronic solutions
From the time a member schedules an appointment
through the claim payment, we’re committed to making
it easy for your office or practice to work with us
electronically. Take advantage of our suite of electronic
transactions and increase your office’s efficiency. Below are
key features and benefits of our electronic transactions.
Note: If you perform transactions through a vendor
other than our provider portal on Availity
®
, functionality
may vary.
Eligibility and benefits inquiry
Our Eligibility and Benefits Inquiry transaction enables
you to request patient eligibility status quickly and easily.
It can help you:
• Verify member eligibility and demographics
• Find detailed financial information, including deductible,
copayment and coinsurance for individual and family
levels
Patient cost estimator*
Our patient cost estimator tool enables you to request
estimates for patients on, or prior to, the date of service
so you can:
• Learn our estimated payment amount
• Get reliable estimates of patient copayments,
coinsurance and deductibles
• Access printable information to help guide financial
discussions with patients prior to (or at the time of) care
• Reduce, and possibly remove, after-the-fact financial
surprises for you and your patients
Precertification adds, inquiries and updates
Our Precertification Add and Precertification Inquiry
transactions are quick, easy ways to request or check the
status of a precertification. Benefits include:
• The ability to access all Aetna benefits plans 24 hours a
day, Monday through Saturday
• The ability to determine if medical precertification is
required via the precertification code search tool
• For Precertification Inquiry, the ability to confirm
whether a valid precertification is present and to check
the status of previously submitted requests
• The ability to make updates to a precertification before
the date of service through our provider portal on
Availity
Complete a Precertification Inquiry transaction and click
on the Update link in the upper right corner of the
response. From there you can:
• Change an admitting or attending provider, facility
or vendor
• Add up to five new diagnosis codes or a note in the
comments field (there is space for 264 characters)
• Update or change admission details, such as changing
the admit date or adding a discharge date
• Add, update or cancel up to five procedure codes and
the associated details
• Make additional changes like canceling an already-
submitted request and adding an end date to an
initial request (as long as the request isn’t more than
180 days from the date of service)
• Submit clinical information in support of pending and
new precertification requests and open concurrent
review cases.
Providers can upload supporting information (like medical
records) through our provider portal on Availity
using a Precertification Submission or Precertification
Inquiry transaction or through Precertification Status
Updates. Users can upload up to six documents at a time
of 32MB each by clicking the Add Files button. We accept
the following file types:
- Microsoft
®
Word (.doc, .docx)
- Microsoft
®
Excel
®
(.xls, .xlsx)
- Adobe
®
PDF (.pdf)
- Images (.gif, .jpg, .jpeg, .png, .tiff)
- Rich text format (.rtf)
Documents are uploaded securely, so you don’t need to
password-protect them. By uploading clinical information
electronically, you no longer need to fax or mail requested
information to us.
*The patient cost estimator does not apply to any Aetna Medicare Advantage plans.
11
Referral add and inquiry
Referral Add and Referral Inquiry transactions are quick,
easy ways to request or check the status of a referral.
You can:
• Request referral authorization
• Inquire about the status of a referral
• Use for any Aetna plans that require a referral
Claims submissions
You can submit all claims electronically and get reimbursed
faster than submitting paper claims. In doing so, you can:
• Receive an automatic acknowledgement for all
submitted claims
• Submit coordination of benefits (COB) claims
electronically
Go to Aetna.com/provider/vendor to see our claims
submission vendor list. On our provider portal, you can
submit professional and institutional claims at no charge,
including COB claims and corrected and voided claims.
If we pend your claim for additional information from you,
you can upload your supporting documents electronically
through our provider portal. Log in and complete a
Claim Status Inquiry transaction. Then, upload your
documents through the Send Attachments link. Users
can upload up to five 32MB documents at a time by
clicking the Attach button. We accept these file types:
• Microsoft Word (.doc, .docx)
• Microsoft Excel (.xls, .xlsx, .csv)
• Adobe PDF (.pdf)
• Images (.gif, .jpg, .jpeg, .png, .tiff)
• Web pages (.json, .xml)
Be sure to include an electronic copy of your Explanation
of Benefits (EOB) statement or Explanation of Provider
Payment (EPP) as one of your documents. The EOB
statement contains a code we use to route your
documentation to the correct area for handling. You can
find EOBs on Availity’s Remittance Viewer.
Documents are uploaded securely, so you don’t need to
password-protect them.
By uploading information electronically, you no longer
need to fax or mail requested information to us. Allow us a
reasonable amount of time to review your documentation
and claim.
Note: This solution isn’t meant to resolve claim
reconsiderations or appeals. Continue to follow your
normal procedures for those events.
Claim status transactions
Our claim status transactions allow you to check on the
status of submitted claims. You can:
• Use Claim Status Inquiry for single member inquiries
• Use Claim Status Report to review multiple claims over
a certain time period
• Request financial status as a follow-up to both Claim
Status Inquiry and Claim Status Report to provide
additional financial details
• In our provider portal, you can initiate a claim
reconsideration. Just click on the Dispute Claim button
in the claim status response
Rules for electronic submission
You can submit claims electronically using:
• The Health Insurance Portability and Accountability Act
(HIPAA) ASC X12N 837 format for professional claims
and the ASC X12N 837 format for institutional claims
• An industry standard successor format, unless your
state requires another format
We ask that you use electronic real-time, HIPAA-compliant
transactions for:
• Eligibility
• Precertification
• Claims status inquiry
• Referrals
Electronic funds transfer (EFT)
EFT allows you to discontinue paper checks and get your
payments up to a week faster than waiting for checks to
arrive in the mail. This option also allows you to:
• Save paper and manage your business effectively with
a convenient audit trail
• Sign up to receive emails when payments have been
transmitted to your bank
Online claims Explanation of Benefits (EOB)
statements
Through our provider portal, you can save more paper
by accessing your EOB statements online. You can also:
• Access all available EOB statements online, 7 days a
week, within 24 hours of claims processing
12
• View, download and save as a PDF, or print EOB statements
• Receive notification when EOB statements
become available
Electronic remittance advice (ERA)
Our ERA transaction provides EOB statement information
electronically. This allows you to:
• Automate your posting processes
• Receive separate ERAs for the same tax ID number for
all associated billing addresses and National Provider
Identifiers (NPIs)
• Enroll in EFT alone
• Enroll in ERA alone
• Enroll in both EFT and ERA
• Make changes on EnrollHub
Capitated providers
If you’re paid on a capitated basis, you need to provide us
with member encounter data. To ask for more information
on submitting encounters, visit our website and select the
Contact Aetna link.
Working through clearinghouse vendors:
transactions by vendor
Learn more about our various electronic transactions,
connectivity options and web-enabled products on our
website.
You can also view a listing of our electronic vendors
and the transactions they support.
Our products
Aetna Benefits Products booklet
The Aetna Benefits Products booklet is an easy-to-use
tool that puts basic product information at your
fingertips. It provides clear, concise information about
our plans including:
• PCP selection and referral requirements
• Precertification instructions
• Laboratory and radiology services
Yo
u can go online to access the Aetna Benefits
Products booklet.
Joining our network
How to apply
Whether you’re with a facility that’s new to Aetna or
you’re a health care professional who’s joining an existing
group, it’s easy to apply for participation in our network.
To start the application process, go to the “Request to
join the Aetna
®
Network” section of our website.
Credentialing (and recredentialing)
You must be credentialed in order to initially participate
in our network. Thereafter, to continue to participate,
you must be recredentialed every three years, unless
otherwise required by state regulations, federal
regulations, or accrediting agency standards.
All credentialing and recredentialing activities are
performed by a National Committee for Quality Assurance
(NCQA)-certified credentialing verification organization.
When using the Council for Affordable Quality Healthcare
(CAQH), ProviderSource, Medversant, or any other
approved credentialing application vendor, remember that
you must designate Aetna as an authorized health plan to
access your credentialing application.
Facilities
During the credentialing process for facilities, we review
to determine if the facility is in good standing with both
state and federal regulatory bodies and if it is accredited
by an Aetna-recognized accrediting entity. If it is not
accredited by an Aetna-recognized accrediting entity, we
check to see if a Centers for Medicare & Medicaid
Services (CMS) survey, a state survey, or other onsite
quality assessment was conducted.
Health care professionals
During the credentialing process for health care
professionals, we review the provider’s qualifications,
practice and performance history.
- In most states, for individual health care professionals,
we use CAQH ProView to get your credentialing
application.
- If you’re located in Washington, or you’re a physician
located in Arkansas, or you’re joining the Allina Health
|Aetna joint venture network in Minnesota, we work
with different vendors to get your credentialing data.
13
How to check your status
Call Aetna Credentialing Customer Service at
1-800-353-1232 (TTY: 711).
Questions?
Please contact any of the organizations below.
• CAQH ProView Help Desk: 1-888-599-1771
• One Health Port and Medversant Help Desk:
1-888-973-4797
• Arkansas State Medical Board: 501-296-1951
Radiology accreditation
We require accreditation to be eligible for reimbursement
for the technical component of advanced diagnostic
imaging procedures. Accreditation can be from:
• The American College of Radiology (ACR)
• The Intersocietal Accreditation Commission (IAC)
• The Joint Commission (TJC), and/or RadSite
The following types of providers require this accreditation:
• Independent diagnostic testing facilities
• Freestanding imaging centers
• Office-based imaging facilities
• Physicians
• Nonphysician practitioners
• Suppliers of advanced diagnostic imaging procedures
For these purposes, advanced diagnostic imaging
procedures exclude X-ray, ultrasound, fluoroscopy and
mammography. Included are:
• Magnetic resonance imaging (MRI)
• Magnetic resonance angiography (MRA)
• Computed tomography (CT)
• Echocardiograms
• Nuclear medicine imaging, such as positron emission
tomography (PET)
• Single photon emission computed tomography (SPECT)
Note:
Providers not accredited by the ACR, IAC, TJC and/or
RadSite will not be eligible for payment for advanced
diagnostic imaging services. The accreditation process
can take 9 to 12 months.
Provider identification numbers
To comply with HIPAA regulations, providers who are
required to have an NPI should include their NPIs on
HIPAA standard transactions.
The HIPAA standard transactions are:
• Claims
• Eligibility and benefits
inquiry
• Claims status inquiry
• Precertification add
• Referral add
In addition to an NPI, claims must also include the billing
provider’s tax identification number (TIN).
Share your National Provider Identifier (NPI)
If you’re a provider who’s required to have an NPI,
make sure you include this link to share NPIs with us.
In addition, share your NPI with other providers who may
need it to conduct electronic claims, referrals or
precertification requests.
Aetna provider identification number (PIN)
Physicians, hospitals and health care professionals
contracted with us also have an Aetna-assigned PIN,
which is used in our internal systems and in certain
transactions on our provider portal.
You should use your NPI in electronic transactions for
purposes of identifying yourself as a provider. However,
you can use your PIN or TIN to identify yourself when
contacting us by other methods.
Accessibility standards and participation criteria
You can find details on our standards in our
participation criteria.
Primary care provider (PCP) responsibilities
PCPs will arrange the overall care and covered services
for members according to their plan. This includes
urgently needed or emergency services.
We have standards for member access to primary care
services. Each PCP is required to have appointment
availability within these time frames:
• Regular or routine care: within 7 calendar days
• Urgent complaint: the same day or within 24 hours
In addition, all participating PCPs must have a reliable
24/7 answering service or machine with a notification
system for call-backs. A recorded message or answering
service that refers members to emergency rooms is not
acceptable. State requirements supersede these
accessibility standards and are located in the Regional
Office Manual Supplements.
14
Specialty care provider responsibilities
We have standards for member access to specialty care
services. Each specialty care provider is required to have
appointments available with these time frames:
• Routine care: within 30 calendar days
• Urgent complaint: the same day or within 24 hours
In addition, all participating specialty care providers must
have a reliable 24/7 answering service or machine with a
notification system for call-backs. A recorded message or
answering service that refers members to emergency
rooms is not acceptable. State requirements supersede
these accessibility standards and are located in the
Regional Office Manual Supplements.
Physician-requested member transfer
Some cases may require a participating physician to ask
an Aetna member to leave their practice when repeated
problems prevent an effective physician–patient
relationship. Such requests can’t be based solely on:
• The filing of a grievance, appeal, a request for external
review or other action related to coverage by the patient
• High usage of resources by the patient
• Any reason that’s not permitted under applicable law
You are required to take the following actions when
requesting to end a specific physician–patient relationship:
• Send the patient a letter informing them of the
termination. The letter should be sent by certified
mail. A copy of it must also be sent to your local Aetna
network manager. For the mailing address, call your
local Aetna office or 1-800-872-3862 (TTY: 711).
In the case of a PCP, we‘ll send the member a letter
informing the member that he or she must select a new
primary care physician and providing instructions on
how to select another primary care physician.
• Support the patient’s continuity of care by giving them
enough notice to make other care arrangements. This is
consistent with the American Medical Association Code
of Medical Ethics, Opinion 8.115.
In addition, upon request, within 30 days of the initial
notification to the member, the physician shall:
• Provide resources or recommendations to the patient
to help locate another participating physician
• Offer to transfer records to the new physician upon
receipt of a signed patient authorization
Medical clinical policy bulletins
Aetna Clinical Policy Bulletins (CPBs) are internally
developed policies that we use as a guide for determining
health care coverage for our members. Our CPBs are
written on selected clinical issues, especially addressing
new medical technologies such as devices, drugs,
procedures and techniques. The CPBs are used as a tool
to be interpreted in conjunction with the member’s
specific benefits plan and after discussions with the
treating physician. Our benefits plans generally exclude
from coverage medical technologies that are considered
experimental and investigational, cosmetic and/or not
medically necessary.
CPBs are continually reviewed and updated to reflect
current information.
We review new medical technologies and new technology
applications regularly. We determine whether and how
such technologies will be considered medically necessary
and/or not experimental/investigational under our
benefits plans.
Our process of assessing technologies begins with a
complete review of the peer-reviewed medical literature
and other recognized references concerning the safety
and effectiveness of the technology. This evaluation
involves analyzing the results of studies published in
peer-reviewed medical journals.
We consider the position statements and clinical practice
guidelines of medical associations and government
agencies, including the Agency for Healthcare Research
and Quality (AHRQ). When applicable, we consider the
regulatory status of a drug or device, including:
• Review by the U.S. Food and Drug Administration (FDA)
• Centers for Medicare & Medicaid Services (CMS)
coverage policies
We develop our CPBs from a review of relevant
information regarding a particular technology. CPBs
are published on our website for public reference.
Note: Under most plans, the term “medically
necessary” refers to health care services that a physician
provides to a patient for the purpose of preventing,
evaluating, diagnosing or treating an illness, injury, disease
or its symptoms. These services adhere to the following
generally accepted standards of medical practice:
• They are clinically appropriate
15
• They are not primarily for the convenience of the
patient, physician or other health care provider
• They are not more costly than an alternative or
sequence of services which are at least as likely to
produce equivalent results
For these purposes, “generally accepted standards of
medical practice” means standards that are based on
credible scientific evidence published in peer-reviewed
medical literature. These standards are generally
recognized by the relevant medical community or
otherwise consistent with the standards above.
Compliance
Nondiscrimination
Federal and state laws prohibit unlawful discrimination in
the treatment of patients on the basis of a number of
factors. These include:
• Race
• Ethnicity
• Gender
• Creed
• Ancestry
• Lawful occupation
• Age
• Religion
• Marital status
• Sex
• Sexual orientation
• Gender identity
• Mental or physical disability
• Medical history
• Color
• National origin
• Place of residence
• Health status
• Claims experience
• Evidence of insurability (including conditions arising out
of acts of domestic violence)
• Genetic information
• Source of payment for services
• Status as private purchasers of a plan or as participants
in publicly financed programs of health care services
• Cost or extent of Provider Services required
• Medicare or Medicaid beneficiary status
All participating physicians should have a documented
policy regarding nondiscrimination.
All participating physicians or health care professionals
may also have accommodation obligations under the
federal Americans with Disabilities Act. The Act requires
that they provide physical access to their offices and
reasonable accommodations for patients and employees
with disabilities.
There are additional requirements for physicians or
health care professionals that are covered entities under
the Section 1557 Nondiscrimination in Health Programs
and Activities Final Rule.
They are required to provide access to medical services,
including diagnostic services, to an individual with a
disability.
Participating physicians or health care professionals may
use different types of accessible medical diagnostic
equipment. Or ensure they have enough staff to help
transfer the patient, as may be needed, to comply.
Members rights and responsibilities
We want you to have a good relationship with our
members and vice versa. That’s why we advise our
members of their rights and responsibilities as they
relate to their selection and interactions with providers.
Advance directives and the Patient
Self-Determination Act (PSDA)
The PSDA is a federal law designed to raise public
awareness of advance directives. An advance directive is
a written statement, completed in advance of a serious
illness, about how one would want medical decisions to
be made for themselves if he or she is incapable of
making them. The two most common forms of advance
directives are the Living Will and the Durable Power of
Attorney for Health Care.
The Centers for Medicare & Medicaid Services (CMS)
strongly urges all practitioners to include documentation
in the medical record regarding whether a Medicare
member has completed an advance directive. This is also
an Aetna medical record documentation requirement.
The patient should complete the Advance Directive
Notification Form. We recommend that each patient
return this form to their PCP so that it may be placed in
their medical file.
We encourage you to discuss advance directives with
your patients.
Note: The PSDA impacts all Aetna members over the
age of 18.
16
Informed consent
All participating physicians and other health care
professionals should:
• Understand and comply with applicable legal
requirements regarding patient informed consent
• Adhere to the policies of the medical community in
which they practice and/or hospitals where they have
admitting privileges
In general, it’s the participating physician’s duty to:
• Give patients adequate information
• Be reasonably sure the patient understands this
information before treating them
Verifying member eligibility
and benefits
How to interpret a member ID card
There are several types of cards, which differ by member
ID number style and copayment information. The
information on member ID cards may also vary
depending on several factors, like the plan sponsor’s
benefits selections, state mandates and plan availability.
For certain products (for example, Workers’ Compensation
and Coventry Auto Solutions), there are no member ID
cards. Contact the payer (the claims adjuster, if known) or
employer to confirm.
Member identification and verification of
eligibility
The following are ways to identify whether a patient is an
Aetna plan member.
Digital ID cards
Twenty-four hours after the plan effective date, members
can access and view their digital ID cards on their member
website, Aetna.com, and on the Aetna Health℠ mobile
app. Members can easily print replacement ID cards from
their Aetna member website. Digital ID cards are identical
to plastic ID cards. Providers can also view an electronic
version of the member’s physical ID card. ID cards allow
you to easily see all the information you need and verify
the patient’s eligibility at the same time. You can view your
Aetna patient’s ID card right from our provider portal.
Member ID cards
• Members should receive an ID card within four weeks of
enrollment. At each visit, your office should ask to see
the member’s ID card and collect the appropriate
copayment, as applicable. Note: Some members will
have digital ID cards. These members may present their
mobile device or a printed copy when getting care.
• Members can access and print some of the information
that appears on their ID card via the Instant Eligibility
feature on their Aetna member website, including:
- Member ID number
- Member name
- Group number
- Member Services telephone number(s)
- Claims address
• Providers can access and print member ID cards from
our provider portal.
- To access the electronic image of the card, the user
must first submit an eligibility request for a member.
- When a successful eligibility response is returned,
a tab which contains an image of an ID card will display
on the screen.
- The user can click the image to view a copy of the
actual member ID card.
A paper or digital version of the member’s information
should be accepted in lieu of an actual member ID card.
No ID card? Use the Eligibility and Benefits Inquiry
transaction. It’s available on our provider portal. Enter
the patient’s full name and date of birth to easily find
patient coverage and detailed benefits information. It’s
accurate and provides greater detail than the ID card.
Group enrollment form
• Members may present a copy of a group enrollment
form to your office. If they do, you should accept it as a
temporary ID. This temporary form is valid for 30 days
after the effective date specified on the form.
• Federal Employees Health Benefits Program (FEHBP)
members may present to your office:
- A copy of the Federal Form 2809 Enrollment Form
- An electronic confirmation of their enrollment from
Employee Express or Annuitant Express.
• When accepting an allowable temporary form of
identification, note the following.
17
- Primary care physicians should check the form to
ensure their Aetna primary care office number is
designated (if applicable for the plan). If the incorrect
doctor or office is listed, claims may be denied or
payments may be misdirected.
- Examine the form to verify the correct copayment.
- Make sure the plan sponsor’s signature is present on
the bottom of the form.
- With the EZEnroll
®
online enrollment option, members
may enroll with Aetna online. Members fill out the
application online and send it to their employer and
then the employer submits it to Aetna. As proof of
enrollment, members should present an enrollment
validation form printed from their personal printer.
The EZEnroll option is not available to Aetna
Medicare
SM
Plan (HMO) members or in certain states.
Note: Aetna Open Access
®
HMO, Aetna Choice
®
POS,
Aetna Choice
®
POS II, and Aetna Medicare℠ Plan (PPO)
members are not required to select a primary care
physician. However, these members are encouraged
to select one so they can take advantage of certain
programs that require members to access care through
their primary care physicians.
Newborn enrollment
This policy applies to most plans, excluding Aetna Medicare
Advantage plans. Contact Member Services for additional
information on newborn enrollment.
Members are instructed to contact their human
resources department to find out their employer’s rule
for the time frame to enroll a newborn.
Members are required to list the selected primary care
office for the newborn on the newborn’s enrollment form.
Note: Under Federal Employees Health Benefits (FEHB)
Program guidelines, FEHB members do not need to
complete an enrollment form if they are currently
enrolled for “family’’ coverage. They should call Member
Services to add additional members to a family contract.
It may take several weeks to process the newborn’s
member ID card once the newborn is enrolled. In the
meantime, use the parent’s member ID card. If the
newborn does not receive their own member ID card
after the appropriate time frame, check for a digital
ID card using Availity. You can also contact our
Provider Contact Center with the number on the
subscriber’s ID card. If the subscriber does not enroll the
child as a dependent within the appropriate time frame,
the subscriber must wait until their next open enrollment
period to enroll the child. The child will not be eligible for
coverage in the interim.
Note for primary care physicians: If your office
provided routine newborn hospital care, submit your
bill electronically to us. If a referral is necessary for a
newborn not yet appearing on the primary office
member list, use the parent’s member ID number.
Verifying benefits
Use the Eligibility and Benefits Inquiry transaction to
obtain member-specific plan details. Check eligibility prior
to a patient’s visit since coverage could have expired or
been suspended. Depending on plan details, transaction
fields may include:
• Copay, deductible and coinsurance
• Exclusions and limitations
• Visits used and visits remaining
• Referral and precertification requirements
Here are some tips to help you complete a transaction.
• Search using the patient’s full first and last names and
date of birth if you don’t have the member ID number.
• Select “Benefit Type” to jump to a specific benefit.
• Under the “Eligibility” link, access your rosters for
HMO capitation.
Verifying your network participation
To verify your network participation, you can use any of
the options below.
• Review your contract.
• Call the Provider Contact Center.
• Go to Aetna.com and check the online
provider search tool.
You can also visit the search tool directly. This search
tool shows those providers that are working with us at a
product level. You can also find network participation in
Availity as you’re viewing eligibility.
18
Precertification
Precertification occurs before inpatient admissions and
select ambulatory procedures and services. Use our
online tools to help you determine if precertification is
required for a particular procedure. Then, submit
precertification requests for those services.
• Precertification Code Search tool — allows you to enter
up to five Current Procedural Terminology (CPT
®
) codes
at a time to determine whether a medical
precertification is required for your patient.
• Online Precertification transaction — allows you to add a
precertification request for those services that require it
and inquire to see if a precertification has been approved.
You can submit a precertification by electronic data
interchange (EDI), through our provider portal or by
phone, using the number on the member’s ID card.
Based on historical experience, we may sometimes allow
particular providers to follow a streamlined
precertification process for certain services.
Visit our website to learn more about precertification.
Emergencies
Medical emergencies
If an Aetna member requires emergency care, they’re
covered 24 hours a day, 7 days a week, anywhere in the
world. In the event of a medical emergency, we advise
our members to follow the guidelines below when
accessing emergency care. This is regardless of whether
they are in or out of an Aetna service area.
• Call 911 or go to the nearest emergency facility. If a
delay would not be detrimental to the patient’s health,
call the primary care physician.
• After assessing and stabilizing the patient’s condition,
the emergency facility should contact the primary care
physician so they can assist the treating physician by
supplying information about the patient’s medical history.
• If the member is admitted to an inpatient facility, the
patient, a family member or friend acting on behalf of
the patient should notify the primary care physician or
Aetna as soon as possible.
• All follow-up care should be coordinated by the primary
care physician, where applicable (medical only).
An “emergency medical condition” involves acute
symptoms that are severe enough that someone with
an average knowledge of health could expect that the
absence of medical attention would result in serious
harm. For pregnant women, the health of both the
woman and her unborn child must be taken into
consideration. State mandates may apply.
Depending on the benefits plan, members traveling outside
their service area or students who are away at school are
covered for emergency and urgently needed care.
Claims submitted to us by the provider that supplied
care must appear to meet the standards for emergency
or urgent care. Otherwise, we may need to review the
records from the emergency visit. In this situation we will
send a request to the treating facility for the records of
the visit and notify the member of the request. If the
member wishes, they may provide us with additional
information regarding the circumstances of the visit.
Follow-up care after emergencies
The primary care physician should coordinate all
follow-up care. In all cases, the primary care physician
must record all information regarding the emergency
visit in the patient’s chart. We require precertification
before we cover any out-of-network follow-up care,
either inside or outside the Aetna service area. You can
obtain precertification electronically or by calling the
number on your patient’s member ID card. Suture
removal, cast removal, X-rays and clinic and emergency
room revisits are some examples of follow-up care.
Note: State regulations and contractual provisions
regarding emergency admissions may, in some cases,
overrule the procedures described in this manual.
19
Claims and billing
Member billing
Billing members for noncovered
services— consent requirements
All of our member plans include certain exclusions.
Common exclusions include services that are considered
experimental and/or investigational (see Medical
Clinical Policy Bulletins for examples). Of course,
services that are not medically necessary are also
generally excluded.
It’s very important that our members have a clear
understanding of their financial responsibilities before
they accept services their plan does not cover. For this
reason, we look to you to inform them if their plan
does not cover those services. If you’re uncertain
whether a service is covered, call us before providing the
service.
If you intend to provide a noncovered service to one
of our members, we require that you do both of the
following prior to providing the service:
• Notify the member that their insurance will not cover
the service. To avoid misunderstandings, we strongly
recommend you provide this notification in writing at
each specific occurrence of a noncovered service. A
general financial responsibility form is not sufficient.
• Obtain the member’s signature to a written consent
statement that says they:
- Understand the service is not covered by their
insurance
- Agree to be financially responsible for the cost
of the service.
It’s important that you retain this signed consent
statement. In the event of a dispute, we may hold you
financially responsible if you can’t produce it.
Billing and balance-billing members
You may bill or charge our members applicable
copayments, coinsurance and/or deductibles. Your
provider contract addresses the circumstances under
which you can bill our members.
However, we want to protect our members from
unnecessary or inappropriate billing. Therefore, you may
not balance bill members when any of the following
occur.
• Claims are denied for administrative reasons such as
lack of referral or authorization when one was required.
• There is a dispute or payment delay involving a payer
(for example, a self-funded plan sponsor). If there is an
issue with a payer, we require that you contact our
Provider Services, advise them of the situation and see if
they can provide guidance on the best way to move
forward.
If a member is incorrectly balance billed, we ask you to
remedy the situation. We may terminate you as a
network provider if you incorrectly balance bill our
members.
Other billing situations
• Billing an Aetna member who has exhausted their
benefits: When a member has exhausted their
benefits, you cannot charge them more than the
contracted rate if you continue to see them. For
example, if a plan covers 10 visits but you provide 12. In
this situation, you cannot bill the member more than the
contracted rate for the two extra visits. And as noted
above, you are also required to:
- Notify the member that their insurance does not
cover the two extra visits
- Obtain the member’s prior written consent to pay for
the two extra visits
• Billing Aetna members for services we denied: we
may adjust or deny payment of covered services upon
utilization management (UM) review. You cannot bill a
member for a service that we denied as a result of our
UM review. If your bill for a covered service is adjusted
because of a UM or bill review, you cannot balance bill
the member for the amount that we do not pay.
An example of this would be if a member is approved
to stay in a hospital for eight days but the hospital does
not release them for 10 days. In this situation:
- We will not cover the two extra days
- The hospital cannot bill the member for the
two extra days
• Billing Aetna members who were not with Aetna
when services were provided: You may bill or charge
individuals who were not our members at the time that
you provided services.
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Initiating a collection action against a payer
We require that you provide written notice before you
initiate any collection action against a payer (for example,
a self-funded plan sponsor). We require that this notice:
• Be given to us and to the payer
• Be given at least 30 days in advance of the
collection action
Concierge medicine
Concierge care is where a provider charges a membership
or other fee for a patient to access services or amenities.
We do not cover membership or administrative fees
for concierge care. And we discourage the provision
of concierge care services by participating providers.
You may charge concierge fees to our members under
the limited circumstances described in the next
paragraph. However, participating providers may not
charge concierge fees for a plan member to access
covered services and/or standard administrative
services. In other words, you can’t charge a member an
annual fee to join or remain in your practice. You also
can’t charge a separate concierge fee for any standard
administrative services, such as prescription orders or
renewals, referrals, medical record maintenance, or
returning phone calls.
While discouraged, you may charge reasonable concierge
fees for a member to access other amenities, such as a
fee in return for preference in scheduling appointments.
You can’t ever discriminate against our members in
concierge pricing and you can’t bill our members more
than you bill any other members for concierge services.
Of course, all concierge fees must comply with all
applicable state and federal laws and regulations. And
you may never bill the member’s plan for concierge fees.
If your practice is going to charge concierge fees, you
must inform your Aetna Network Manager in advance.
We reserve the right to indicate whether a provider
practices concierge care in our provider search tool and
other materials. Concierge fees are prohibited for Aetna
Medicare Advantage members.
Claims information
Go to Aetna.com/health-care-professionals/
claims-payment-reimbursement.html to find all our
claims, payment and reimbursement tools and guidelines.
Electronic claims submission
Submit all claims electronically for your patients,
regardless of their benefits plans.
• If you are already using a vendor, add Aetna to your list
of payers.
• To view a list of our participating claims vendors, visit
Aetna.com/provider/vendor.
• Send professional and institutional claims free of
charge from our provider portal.
We typically do not need attachments. If we do, we’ll let
you know what we need. Then, you can submit your
supporting documentation electronically through our
provider portal.
Claims submission tips
To ensure accurate and timely claims payment:
• Review rejection reports from your vendor
• Correct and resubmit rejected claims electronically
through your vendor
• Ensure the member and patient names and ID numbers
are correct
• Ensure procedure and diagnosis codes are valid
Disagree with a claim decision?
Write to the PO box listed on the EOB statement or
the denial letter related to the issue being disputed.
Include the reason(s) for the disagreement. Or call our
Provider Contact Center (see Key Contacts on page 9).
Go to Aetna.com/health-care-professionals/
disputes-appeals.html for more information.
Claims addresses
If your practice management or hospital information
system requires a claims address for submission of
electronic claims, or if your office does not have
electronic capabilities, refer to the table below for the
claims address for your state.
Medical provider
location by state
Claims mailing
address
AL, AK, AR, AZ, CA, FL,
GA, HI, ID, LA, MS, NC,
NM, NV, OR, SC, TN,
UT and WA
Aetna
PO Box 14079
Lexington, KY
40512-4079
CO, CT, DC, DE, IA, IL,
IN, KS, KY, MA, MD,
ME, MI, MN, MO, MT,
ND, NE, NH, NJ, NY,
OH, OK, PA, RI, SD, TX,
VA, VT, WI, WV and WY
Aetna
PO Box 981106
El Paso, TX
79998-1106
21
- For all Aetna Medicare Advantage and Aetna Student
Health
SM
plans, use the El Paso, TX, claims mailing
address.
- For all Aetna Voluntary Plans, use the Lexington, KY,
claims mailing address and the payer ID “57604.”
- For Aetna Signature Administrators
®
plans, Coventry
Health Care Workers Compensation, Inc. plans,
Meritain Health
®
and Schaller Anderson (Medicaid),
refer to the member ID card.
Clean claims
We know it’s important to you that your office gets paid
promptly. To reduce payment delays, have your office
submit “clean claims.” A clean claim is a claim that is
received in a timely manner and includes all the
information we need to process it for payment.
Unless otherwise required by law or regulation, clean
claims include all of the following:
• Detailed and descriptive medical and patient data
• A corresponding referral (whether in paper or
electronic format), if required for the applicable claim
• All the data elements of the UB-04 or CMS-1500 (or
successor standard) forms (including but not limited
to member identification number, National Provider
Identifier (NPI), date(s) of service, and a complete and
accurate breakdown of services)
In addition, a clean claim:
• Doesn’t involve coordination of benefits
• Has no defect or error (including any new procedures
with no CPT codes, experimental procedures or other
circumstances not contemplated at the time of execution
of your agreement) that prevents timely adjudication
Coordination of benefits
We coordinate benefits as allowed by state or federal
law. If there is no applicable law, then we coordinate
according to the member’s plan.
Coordination of benefits (COB) establishes the order in
which benefits are paid and the amount by which the
secondary plan may reduce its benefits. We follow the
National Association of Insurance Commissioners Model
Law in establishing the order of benefits. COB ensures
that the combined payments of all plans do not add up
to more than the covered health care expenses.
We use two different methods to calculate COB:
• 100% Allowable (Standard Allowable Calculation)
• This is the method used under most state laws.
• The benefits paid by both plans will equal no more than
the total allowable expense.
• An allowable expense is defined as any necessary and
reasonable health expense, part or all of which is
covered under any of the plans covering the person for
whom the claim is made.
• Maintenance of Benefits (MOB)
- This is a method used by many self-funded plans.
- Under MOB, a secondary plan may reduce its benefits
to the lesser of the following two calculations:
- What it would have paid had it been the
primary plan
- What it would have paid minus the primary
plan’s payment
If the primary plan
benefit is:
Then:
Equal to or more than
the Aetna benefit
Aetna will not pay a
benefit
Less than the Aetna
benefit
Aetna will pay the
difference between the
primary plan’s benefit
and the Aetna benefit
Aetna is responsible for coordinating benefits based on
the member’s benefits plan and applicable law. The
primary carrier’s negotiated fee is not used to determine
normal Aetna benefits. See the following example:
Primary plan contract
with physician
Aetna contract with
physician
$1,500 billed charges $1,500 billed charges
$1,000 primary plan’s
negotiated fee
$1,200 Aetna negotiated
x 80% coinsurance rate =
$800 primary plan
payment
x 80% coinsurance rate =
$960 normal Aetna
benefit – $800 primary
plan’s payment = $160
Aetna payment
22
Birthday rule
Unless a court order dictates otherwise, we follow the
birthday rule for all employer groups and provider
contracts regarding dependent children of parents not
separated or divorced.
• The benefits of the plan of the parent whose birthday
falls earlier in a year are determined before those of the
plan of the parent whose birthday falls later in the year.
• If both parents have the same birthday, we make the
determination based on length of coverage.
• The benefits of the plan that covered the parent longer
are determined before those of the plan that covered
the other parent for a shorter period of time.
Medicare Secondary Payer
Medicare Secondary Payer (MSP) is the term used by
Medicare when Medicare is not responsible for paying
claims first. Under MSP, an active employee of a group
plan with 20 employees has the group plan as their
primary payer when covered by both the group plan and
Medicare. MSP also establishes rules for individuals who
are disabled and for those with end-stage renal disease.
The correct order of claims determination is established
by identifying the type of Aetna coverage and the reason
for Medicare entitlement.
Medicare and Medicaid dual eligibles
Medicare and Medicaid “dual eligibles” are individuals
who are entitled to both Medicare Part A and/or Part B
and are eligible for some form of Medicaid benefit.
Medicare and Medicaid relationship
People with Medicare who have limited income and
resources may get help paying for their out-of-pocket
medical expenses from their state Medicaid program.
There are various benefits that may be available to “dual
eligibles.” These benefits are sometimes also called
“Medicare Savings Programs.”
For people who are eligible for full Medicaid coverage,
the Medicaid program supplements Medicare coverage
by providing certain services and supplies that are
covered under their state’s Medicaid program. Services
or supplies that are covered by both programs will be
paid first by Medicare. The difference will be paid by
Medicaid, up to the state’s payment limit.
Medicaid also covers additional services (for example,
nursing facility care beyond the 100-day limit covered by
Medicare, prescription drugs, eyeglasses and hearing
aids). Limited Medicaid benefits are also available to pay
for out-of-pocket Medicare cost-sharing expenses for
certain other Medicare beneficiaries.
Aetna Medicare Advantage
Dual eligibles receive their prescription drug benefit
(Part D) through Medicare. Dual eligibles may enroll in
stand-alone Medicare prescription drug plans (PDPs) or
Aetna Medicare Advantage (MA) plans that incorporate a
prescription drug benefit (MA-PDs). We offer both types
of insurance products to Medicare-eligible beneficiaries.
If a dual eligible enrolls in an Aetna Medicare Advantage
plan, then the provider must bill Aetna as the primary
payer and the state Medicaid plan as the secondary
payer. The provider must notify patients prior to
providing services if the provider does not accept
payments from state Medicaid plans as payment in full.
Medicare Part D plans
It is possible that an individual may be covered under
both a Part D Medicare prescription drug plan and
another health plan that provides prescription drug
coverage or financial assistance to Medicare
Part D–eligible individuals (including non-Medigap
individual market insurance policies). In that event,
covered benefits must be coordinated between such
plans in accordance with CMS requirements and any
subsequent guidance from CMS.
Note: State mandates take precedence over Aetna
standards.
Working aged
The “working aged” are employed people age 65 or older,
and people age 65 or older with employed spouses of
any age, who have Employer Group Health Plan (EGHP)
coverage because of their or their spouse’s current
employment.
Aetna is the primary payer to Medicare for the “working
aged” if the employer group has 20 or more employees.
If the employer group has fewer than 20 employees,
Aetna is the secondary payer to Medicare, except for
certain multi-employer plans.
Motor vehicle accident
Benefits for injuries caused by a motor vehicle accident
which are compensable through the Personal Injury
Protection (PIP) section of the patient’s no-fault
automobile insurance policy are primary over Aetna.
If automobile insurance is not available to the patient and
Aetna policies, procedures and programs were followed,
we would consider the auto-related services for coverage.
23
Some states give the insured an option to choose their
primary coverage for PIP. If the insured elects Aetna over
their automobile insurance company, we will require proof
that the insured has elected Aetna as primary insurer at
the time the accident occurred. All procedures must be
covered services and referred by the patient’s primary
care physician, when applicable (excluding emergency
procedures). All Aetna policies, procedures and programs
must be followed for benefits consideration.
Patients who have a motor vehicle accident, and whose
Aetna coverage is secondary to PIP, should still have all
care coordinated through the primary care physician
(if applicable). The primary care physician should issue
referrals to participating physicians and health care
professionals and place the information in the patient’s file.
Note: Subrogation is prohibited in Virginia. When
providing covered services to a patient who has been
involved in a motor vehicle accident and who has a fully
insured plan, providers must seek payment from the
patient’s health insurer first.
Claims payment policy — rebundling
We rebundle claims to the primary procedure codes for
those services considered part of, incidental to, or
inclusive of the primary procedure. Rebundling allows for
other adjustments such as inappropriate billing or
coding. Examples of these include:
• Duplicative procedures or claim submissions
• Mutually exclusive procedures
• Gender and procedure mismatches
• Age and procedure mismatches
The commercial software packages that we use include
rebundling logic. This logic is based on Medicare and/or
other industry standards.
Overpayment recovery
For commercial plans, overpayment notifications are
typically sent within 24 months of the payment issue
date. A different time frame is used if applicable law
allows it and/or fraud or other intentional misconduct by
the provider occurs.
For Medicare plans, overpayment notifications are
typically sent within 36 months of the payment issue date.
Both commercial and Medicare time frames are subject
to change in order to comply with regulatory or
legislative requirements.
Audits
Hospital bill audit
The purpose of a hospital bill audit is to review the
itemized bill against the claim and the medical record.
This audit is used on claims where we pay a percentage
of billed dollars (charges). In addition, the audits identify
items that may not have been ordered by the physician
or were not supported in the medical record.
The audits exclude outpatient hospital claims paying a
percent of billed dollars (charges).
Diagnosis-related group (DRG) audit
DRG audits ensure diagnosis and procedures codes are
assigned accurately through medical record audits. A
detailed narrative and proposed DRG revisions are
presented to the provider for acceptance.
A DRG short-stay audit is a post-service, post-payment
review of Medicare risk inpatient claims paid under a DRG
methodology to validate that the provider appropriately
billed and received payment for the setting of care in
which the patient was treated.
Implant audit
Implant audits ensure providers are complying with the
contract cost limitation language on implants and high
cost drug reimbursement. This audit focuses on claims
that bill with revenue codes 274–279. Implant audits
occur through review of implant log/invoice and
Medication Administration Record. A detailed narrative
is sent to the provider with the audit findings.
Prepay audit
We may review our members’ medical records before
certain claims are processed. This review includes, but
is not limited to, itemized bills or more specific detail for
claims contracted on a percentage-of-charges basis.
The review may result in payment being denied for
duplicate charges, errors in billing or categorization of
capital equipment.
OrthoNet
We use OrthoNet to review our members’ medical
records before certain claims are processed. When a
24
claim is selected for review, we’ll ask the provider for
copies of the patient’s medical records. OrthoNet will
compare the claims coding to the services provided.
Affected specialties:
• Dermatology
• Ear, nose and throat
(otolaryngology)
• Hand surgery
• Neurology
• Neurosurgery
• Orthopedic surgery
•
Pain management
• Physiatry
• Plastic surgery
• Podiatry
• Sports medicine
• Urology
Where to send Aetna records
If your office is asked to send records to Aetna, use any
of the ways below to do so.
• Fax: 859-455-8650
• Mail: Aetna, PO Box 14079, Lexington, KY 40512-4079
When faxing or mailing records, be sure to include a
cover sheet with “CODE: ONET” at the top of the page.
We’ll also need the following information:
• Aetna member ID
• Date of service
• Servicing provider name
• Servicing provider tax identification number and/or the
Aetna provider ID number
Medical records
Record keeping
Participating practitioner medical record criteria
Aetna health plans have established medical record
criteria and documentation standards. Their intent is to
facilitate communication and coordination of care and
promote effective patient care. These criteria provide a
guideline for organizing and documenting diagnostic
procedures and treatments.
We expect all participating practitioners to comply with
these documentation standards, as well as state laws
and regulations that require biennial medical record
audits. We use the same criteria to score those audits,
which are as follows:
• We award one point for each element documented
compliantly.
• We award zero points for those that are not compliant.
Performance goals are established to assess the quality of
medical record keeping practices, and audits are conducted
no less than every two years. We calculate the audit score
by dividing the number of compliant points by the total
number of applicable points. The performance goal is 85%.
Organization
• Each page has member’s name and date of birth on it.
- The member’s name and date of birth should be
recorded on each page of the medical record (for
example, all notes, lab reports and consult reports).
(1 point)
• The member’s personal data (gender, date of birth,
address, occupation, home and work phone numbers,
marital status) is documented.
- Each record must contain appropriate biographical
and personal data including age, sex, race, address,
employer, home and work telephone numbers,
emergency contact and marital status.
- All members must have their own chart — no family
charts. (1 point)
- A centralized medical record for the provision of
prenatal care and all other services must be
maintained (prenatal only). (1 point)
• All entries in the record contain the author’s signature
or initials or electronic identifier (stamped signatures
are not acceptable).*
- The provider of service for face-to-face encounters
must be appropriately identified on medical records
via their signature and their physician-specialty
credentials (for example, MD, DO and DPM). Here are
examples of acceptable physician signatures:
- Handwritten signature or initials
- Electronic signature with authentication by the
respective provider
- Facsimiles of original written or electronic signatures
This means that the credentials for the provider
of services must be somewhere on the medical
record— either next to the provider’s signature or
preprinted with the provider’s name on the group
practice’s stationery. If the provider of services is not
*This is assessed for Medical Record Keeping Practices based on guidelines from the National Committee for Quality
Assurance (NCQA), CMS, insurance regulations and Aetna.
25
listed on the stationery, then the credentials must be
part of the signature for that provider. (1 point)
• All entries are dated. (1 point)*
• All entries are legible to someone other than the writer.*
- The medical record should be complete and legible.
Illegible medical record entries can lead to
misunderstanding and serious patient injury. (1 point)
• Medications are noted, including dosages and dated
status of prescription (active or discontinued) or date
of initial or refill prescription.*
- Evidence of prescribed medications, including
dosages and dates of initial or refill prescriptions must
be present in the record. This list should be updated
each visit. (1 point)
• Medication allergy and adverse reactions or lack
thereof prominently noted.*
- Allergies and adverse reactions to medications are
prominently noted in chart or the lack thereof is noted
as NKA (no known allergies) or NKDA (no known drug
allergies). (1 point)
• An up-to-date problem list is completed including
significant illnesses and medical and psychological
conditions.*
- A problem list recorded with notations must be
present and include any significant illness or medical
and/or psychological condition found in the history or
in previous encounters. The problem list must be
comprehensive and show evaluation and treatment
for each condition that relates to an ICD-10 diagnosis
code on the date of service. A problem list should be
either a classical separate listing of problems or an
updated summary of problems in the progress note
section (usually a periodic health exam). The latter
type list should be updated at least annually and
should include health maintenance. A repetitive listing
of problems within progress notes is acceptable. A
blank problem list receives a score of zero. (1 point)
• Past medical history is completed (for members seen
three or more times) and is easily identified and includes
dates of serious accidents, operations and illnesses. For
children and adolescents (18 years and younger), past
medical history relates to dates of prenatal care, birth,
operations and childhood illnesses.*
- Past history including experiences with illnesses,
operations, injuries and treatments must be
documented. Family history including a review of
medical event, diseases and hereditary conditions
that may place the member at risk must be
documented. (1 point)
• History and physical (H&P) documents have subjective
and objective information for the presenting problem.*
- Past medical history including physical examinations,
necessary treatments and possible risk factors for the
member relevant to the particular treatment are
noted. (1 point)
• For members 14 years and older, there is appropriate
notation concerning the use of cigarettes, alcohol
and substances (for members seen 3 or more times,
substance abuse history must be queried).
- For members 14 years and older, a score of 1 requires
a response to an inquiry concerning alcohol, smoking
and/or substance abuse history as part of risk screening
in support of preventive health. For members under the
age of 14 years, the score will be N/A. (1 point)
- Note regarding follow-up care, calls and visits. Specific
time of return is noted in weeks, months or as needed.
- Encounter forms or notes have a notation regarding
follow-up care, calls or visits when indicated. The
specific time of return is noted in weeks, months or
as needed (i.e., PRN). (1 point)
• An immunization record has been initiated for children
and a history for adults.
- An immunization record (for children) which includes
the name of the vaccine and date of administration
or disease (for example, chickenpox) is up to date or
an appropriate history has been made in the medical
record (for adults). Member-reported data is
acceptable. (1 point)
• Preventive screenings and services are offered
according to Aetna guidelines.*
- There is evidence that preventive screenings and
services are offered in accordance with the
organization’s practice guidelines. Preventive screenings
specific to the member’s age, gender and illness (for
example, mammography, immunizations, Pap smear,
human papilloma virus (HPV), body-mass index (BMI)
value for adults, BMI percentiles for ages 15 and under,
colorectal cancer screening, diabetic eye exams) are
documented. Documentation should include screening
date and result. (1 point)
- For children and adolescents there should be
documentation of counseling for nutrition and
physical activity.
*This is assessed for Medical Record Keeping Practices based on guidelines from the National Committee for Quality
Assurance (NCQA), CMS, insurance regulations and Aetna.
26
• Documentation about advance directives (whether
executed or not) is in a prominent place in the
member’s record (except for those under age 18).*
- There is evidence of advance directives noted in a
prominent place in the record (1 point) and whether
or not the advance directive has been executed in the
chart for members over 18 years of age. (1 point)
• Treatment plan is documented.*
- There is documentation of clinical findings and
evaluation for each visit (presenting complaints,
pain management, diagnosis and treatment plan,
prescription, referral authorization, studies,
instructions). (1 point)
• Working diagnoses are consistent with findings.*
- There is a documented reason for the visit. The
progress note contains appropriate subjective and
objective information pertinent to the member’s
presenting complaints for each visit. (1 point)
• There is no evidence that the member is at inappropriate
risk. Possible risk factors for the member relevant to
particular treatment are noted.*
- There is no evidence that the member is placed at
inappropriate risk by a diagnostic or therapeutic
procedure. Diagnostic and therapeutic procedures
are appropriate for the member’s diagnosis and
risk factors. Examples: a) Member has complaint of
right-hip pain and an X-ray of the right hip is ordered.
b) Abnormal lab and imaging study results do not have
an explicit note regarding follow-up plans. (1 point)
Examination
Blood pressure, weight, height, BMI value or BMI
percentile measured and recorded at least annually, if
the member accesses care. (1 point)
Studies
• Lab and other studies are ordered, as appropriate.
- If a diagnostic service (test or procedure) is ordered,
planned, scheduled, or performed at the time of
the evaluation and management (E/M) encounter,
the type of service — for example, lab work or an
X-ray— should be documented. (1 point)
• There is evidence that the physician has reviewed lab,
X-ray or biopsy results (signed or initialed reports), and
the member has been notified of results before filing in
the record.
- There is evidence of physician review of lab work,
X-ray or biopsy results or other studies by either
signing or initialing reports or documentation of the
results in the progress notes. Abnormal lab and
imaging study results have an explicit note regarding
follow-up plans. (1 point)
Communication
• There is documentation of communications contact
with referred specialist.*
- The PCP or managing practitioner coordinates and
manages the care of the member. If a consultation or
referral is made to a specialist, there is documentation
of communication between the specialist and the PCP
with a notation that the physician has seen it. And there
is evidence of discharge summaries from hospitals,
home health agencies (HHAs) and skilled-nursing
facilities (SNFs), if applicable. If there is no evidence of
referral or other facility services, mark N/A. (1 point)
• There is documentation indicating the patient’s
preferred language (California only).**
• There is documentation of an offer of a qualified
interpreter, and the enrollee’s refusal, if interpretation
services are declined (California only).*
Records maintenance and access
Maintenance
You need to maintain medical records in a current,
detailed, organized and comprehensive manner in
accordance with customary medical practice, applicable
laws and accreditation standards. You are required to
keep our members’ information confidential and stored
securely. You must also ensure your staff members
receive periodic training on member information
confidentiality. Only authorized personnel should have
access to medical records.
Member record access
We have the right to access confidential medical records
of Aetna members for the purpose of claims payment,
assessing quality of care (including medical evaluations
and audits), and performing utilization management
functions. We may request medical records as a part of
our participation in the Healthcare Effectiveness Data
and Information Set (HEDIS
®
). HIPAA privacy regulations
allow for sharing of protected health information (PHI)
*T his is assessed for Medical Record Keeping Practices based on guidelines from the National Committee for Quality
Assurance (NCQA), CMS, insurance regulations and Aetna.
**F or benefits plans that require the issuance of referrals for specialist care in southern New Jersey, Pennsylvania,
Maryland, Virginia and the District of Columbia, the member should be directed to their PCP for referrals for
laboratory and radiology services.
27
for the purpose of making decisions around treatment,
payment or health plan operations.
Privacy practices
Protecting our members’ health information is one of
our top priorities. Our members expect and rely on us to
protect their protected health information (PHI). In turn,
we expect our participating physicians, facilities, and
office staff to safeguard our member’s PHI, and treat it
with the same care and consideration.
Our references to PHI include information that relates to:
• A patient’s physical or mental health or condition
• The provision of health care to the patient
• Payment for the provision of health care to the patient
Our references to PHI do not include:
• Publicly available information
• Information that is available or reported in a summarized
or aggregate fashion but does not identify the patient
We use PHI internally or share it with our affiliates when
it is necessary or appropriate to do so. For example, in
connection with a patient’s care or treatment, the
operation of our health plans, or other related activities.
In these circumstances, we may disclose PHI to:
• Health care professionals
• Payers, including:
- Health care provider organizations
- Self-funded health plans
- Others who may be financially responsible for
payment for the services or benefits patients receive
under their plans)
• Other insurers, third-party administrators, vendors,
consultants, government authorities and their
respective agents
The ways in which we use PHI include:
• Auditing and anti-fraud activities
• Claims payments
• Compliance with legal and regulatory requirements
• Coordination of care and benefits
• Coverage reviews*
• Data and information systems management
• Disease and case management
• Due diligence activities in connection with the purchase
or sale of some, or all, of our business.
• Early detection
• Formulary management
• Health claims analysis and reporting
• Health services research
• Litigation proceedings
• Performance measurement and outcome assessments
• Preventive health
• Quality assessment and improvement activities
• Transfer of policies or contracts to and from other
insurers, HMOs, and third-party administrators or sale
of some or all of our business
• Underwriting activities
• Utilization reviews and management insurers, HMOs,
and third-party administrators or sale of some or all
of our business
Additional information about privacy and security
practices at Aetna, including the following documents,
are available at the Aetna Privacy Center:
• The Aetna Notice of Privacy Practices by plan type
• The Aetna Web and Mobile Privacy Statement
Like Aetna, participating providers are covered entities
under HIPAA. They are required to keep PHI confidential,
and to adhere to their obligations under the HIPAA
Privacy Rule. All health care professionals and employed
staff who have access to member records or confidential
member information should be made aware of their
legal, ethical, and moral obligations regarding member
confidentiality.
The federal Department of Health and Human Services
provides helpful information. This includes but is not
limited to information on the obligations of Covered
Entities. You can access that information here: HIPAA
for Professionals.
*For these purposes, “coverage” means either of the following:
• The determination of whether or not the particular service or treatment is a covered benefit pursuant to the terms
of the particular member’s benefits plan
• The determination of where a provider is required to comply with our utilization management programs, whether
or not the particular service or treatment is payable under the terms of the provider agreement
28
Referrals
Referral policies
In benefits plans that require the issuance of referrals for
specialist care, the primary care physician is responsible
for coordinating their patients’ health care. If it’s necessary
for the patient to see a specialist, other than for
direct-access services or emergency care, the primary
care physician must issue a referral prior to the patient’s
visit to the specialist.* The referral must be for covered
benefits under the plan.
To confirm covered benefits, you can submit an inquiry
through the Eligibility and Benefits Inquiry transaction
or call the number on your patient’s member ID card.
Referrals should not be retroactive. We may adjust or
deny payment for retroactive referrals. If your patient
visits a specialist without a referral, depending on their
plan type, the patient may be responsible for payment
for all services rendered or for paying a deductible and
coinsurance.
In addition to the requirement that primary care
physicians review every referral issued by their practice,
we recommend that the initial consultative referral be
authorized for one visit, except when the patient is
either known to have a predicted need for more visits
or involved in an ongoing process of care.
This encourages communication from the specialist to
the primary care physician.
After an initial consultation, additional referrals from the
primary care physician are required if the specialist:
• Wishes to provide additional services not originally
requested on the referral
• Refers their patient to a second specialist
• Requires visits that will exceed the number of visits
initially authorized by the primary care physician
• Will need an extension beyond the referral expiration date
We require specialists to communicate with the referring
physician in a timely fashion. After receiving the
consultation report from the specialist, the primary
care physician can consider the appropriate course of
treatment (for example, referrals for additional services
and/or follow-up care, if needed).
Referrals may be authorized for consultation and
treatment (C&T) using CPT code “99499.” In most areas,
C&T referrals do not need to specify the procedures to
be performed by the specialist.** Specialists will be
reimbursed for any associated covered procedure
performed in an office setting, in accordance with
current claims processing guidelines.
Referrals do not permit specialists to refer members to
another specialist for care. If this is necessary, patients
must get a referral from their primary care physician to
see another specialist. This referral is not a guarantee of
payment. Payment is subject to eligibility on the date of
service, plan benefits, limitations and exclusions,
pre-existing condition limitations, and patient liability
under the plan.
No plans require a referral for emergency services. Some
plans do not require the issuance of a referral. In those
plans, a patient may self-refer to either participating
or nonparticipating physicians or other health care
professionals. The patient is responsible for paying
any applicable copayment, deductible and/or
coinsurance for self-referred benefits. See the
“Utilization Management”section on page 30 for
rules regarding pre-authorization for certain services.
In Aetna Open Access
®
plans, referrals also are not
necessary. A patient may self-refer to any participating
physician/health care professional.
We may terminate our agreement if you refer members
to nonparticipating providers without one of the following.
• Sound clinical reasons
• Our advance approval
• Emergency services
• The member’s request for referral to an
out-of-network provider after notice and
informed consent of the patient has been
documented in writing
Member’s consent for nonparticipating
providers’ referrals
You may arrange services with a provider who doesn’t
participate with us if the member’s plan allows it. In that
event, you should acquire the member’s written consent.
The consent should state that the member has been
advised of the following:
• The hospital, facility, or provider is not a
participating provider.
*Referrals in Texas are only valid for 30 calendar days. After that time, another referral is needed.
** This is assessed for Medical Record Keeping Practices based on guidelines from the National Committee for Quality
Assurance (NCQA), CMS, insurance regulations and Aetna.
29
• The member’s plan may provide reduced benefits.
• The nonparticipating provider will not be restricted
to seeking payment only from Aetna. The provider may
bill the member for amounts other than deductibles,
copayments, coinsurance, and medical services not
covered under the plan.
• You have an affiliation or financial ownership interest
in or with the nonparticipating provider, if that is the case.
Referral processes
Electronic referrals should be issued for all plans that
require referrals (see the “Aetna Benefits Products
Booklet” section on page 13). For information on
submitting electronic referrals, see the ”Electronic
Solutions” section on page 11.
For obstetric testing or infertility services, refer to the
Women’s Health Programs and Policy Manual, available
at Provider Manuals.
Note: providers who participate with us through an
independent practice association (IPA) or physician
hospital organization (PHO) should consult their IPA or
PHO on plan policies and procedures. Some of these
referral guidelines may not apply. (Physicians and other
health care professionals in upstate New York should
continue to work with Aetna and/or their respective IPA
in their usual manner)
Utilization management
Overview
Our Care Management model integrates available
programs and services. This includes case management,
disease management and specialty areas such as
behavioral health. Our role is to help coordinate health
care and to encourage members to be informed
participants in health care decision-making.
Our care management activities for hospitalized
members include:
• Focused discharge planning to help with the member’s
transition to the next level of care
• Targeted, concurrent review of the member’s hospital
course of treatment to evaluate the appropriate level
of coverage* for medical services
Utilization management and standards
We use utilization review to promote adherence to
accepted medical treatment standards. Additionally,
utilization review encourages participating physicians
to minimize unnecessary medical costs consistent with
sound medical judgment. We expect participating
providers to adhere to the following requirements:
• Participate, as requested, and collaborate with Aetna
utilization review, care management and quality
improvement programs and with all other related
programs (as modified from time to time) and decisions
with respect to all members.
• Regularly interact and cooperate with Aetna clinicians.
• Abide by Aetna participation criteria and procedures,
including site visits and medical chart reviews, and
submit to these processes biannually, annually, or
otherwise, when applicable.
• Cooperate to help us review and transition members
hospitalized in a nonparticipating facility to a
participating facility.
• Obtain advance authorization from Aetna prior to any
nonemergency admission. In addition, when a member
requires an emergency hospital admission, notify us,
according to our rules, policies and procedures in effect.
• To the extent medically appropriate and required by the
plan’s terms, refer or admit members only to participating
providers for covered services. Provide these providers
with complete information on treatment procedures
and diagnostic tests performed prior to the referral
or admission.
• Abide by CMS’s Medicare Outpatient Observation Notice
(MOON) requirement provided to members and related
to observation services.
You may have an Aetna patient who requires services
under an Aetna specialty program. If they do, we expect
you to work with us to transfer the member’s care to a
specialty program provider.
*This is assessed for Medical Record Keeping Practices based on guidelines from the National Committee for Quality
Assurance (NCQA), CMS, insurance regulations and Aetna.
30
How to contact us about utilization
management issues
• Our staff, including medical directors, are available to
receive provider and member inquiries about utilization
management issues. You can call us during and after
business hours via toll-free phone numbers.
• Health care providers may contact us during normal
business hours (8 AM to 5 PM, Monday through Friday*)
by calling the toll-free precertification number on the
member ID card.
• When only a Member Services number is on the card,
you’ll be directed to the Precertification Unit through a
phone prompt or a Member Services representative.
• Members and providers may access staff on weekends,
company holidays, and after business hours through
the same toll-free phone numbers.
Utilization review policies
Summaries of utilization review policies, including
precertification, concurrent review, discharge planning
and retrospective review are located on our public
website to determine:
• Whether or not the particular service or treatment is
a covered benefit under the member’s benefits plan
• When a provider is required to comply with Aetna
utilization management programs
• Whether or not the particular service or treatment is
payable under the terms of the provider agreement
How we determine coverage
Aetna Medical Directors make all coverage denial
decisions that involve clinical issues. Only Aetna Medical
Directors and licensed dentists, oral and maxillofacial
surgeons, psychiatrists, psychologists, board-certified
behavior analysts-doctoral (BCBA-D) and pharmacists
make denial decisions for reasons related to medical
necessity. (Licensed dentists, pharmacists and
psychologists review coverage requests as permitted by
state regulations.) Where state law mandates, utilization
review coverage denials are made, as applicable, by a
physician or pharmacist licensed to practice in that state.
Patient Management staff use evidence-based clinical
guidelines from nationally recognized authorities to guide
utilization management decisions involving precertification,
inpatient review, discharge planning and retrospective
review. Staff use the following criteria as guides in making
coverage determinations, which are based on information
about the specific member’s clinical condition:
• MCGTM guidelines (Seattle, WA: MCG Health, LLC)
• Clinical Policy Bulletins (CPBs) or Pharmacy Clinical
Criteria — Clinical Policy Bulletins (PCPBs) (based on
peer-reviewed, published medical literature)
• Centers for Medicare & Medicaid Services (CMS)
National Coverage Determinations (NCDs), Local
Coverage Determinations (LCDs) and the Medicare
Benefit Policy Manual
• National Comprehensive Cancer Network (NCCN)
Guidelines (Category 1 and 2A recommendations)
• Level of Care Assessment Tool (LOCAT)
• Applied Behavior Analysis (ABA) Medical Necessity Guide
• The American Society of Addiction Medicine (ASAM)
Criteria: Treatment for Addictive, Substance-Related,
and Co-Occurring Conditions, Third Edition.
This content is copyrighted. Contact the American Society
of Addiction Medicine at ASAMcriteria@asam.org for
information on how to purchase it.
The Standards for Reasonable Cost Control and Utilization
Review for Chemical Dependency Treatment Centers (28TAC
§§3.8001-3.8030) (formerly known as TCADA), are used in
place of ASAM for chemical dependency treatment provided
in Texas. And The Level of Care for Alcohol and Drug
Treatment Referral (LOCADTR) is used in place of ASAM for
chemical dependency treatment provided in New York.
Participating physicians may ask for a hard copy of
the criteria that were used to make a determination
by contacting our Provider Contact Center at
1-888-632-3862 (TTY: 711).
We base decisions on the appropriateness of care and
service. We review coverage requests to determine if the
requested service is a covered benefit under the terms of
the member’s plan and is being delivered consistent with
established guidelines. Aetna offers providers an
opportunity to present additional information and discuss
their cases with a peer-to-peer reviewer as part of the
utilization review coverage determination process. The
timing of the review incorporates state, federal, CMS and
NCQA requirements. If we deny a request for coverage, the
member (or a physician acting on the member’s behalf)
*For all continental U.S. time zones; hours of operation may differ based on state regulations. Texas: 6 AM to 6 PM CT,
Monday through Friday, and 9 AM to 12 noon CT on weekends and legal holidays. Phone recording systems are in use
for all other times.
31
may appeal this decision through the complaint and appeal
process. Depending on the specific circumstances, the
appeal may be made, as applicable to:
• A government agency
• The plan sponsor
• An external utilization review organization that uses
independent physician reviewers
We do not reward physicians or other individuals who
conduct utilization reviews for issuing denials of coverage
or for creating barriers to care or service. Financial
incentives for utilization management decision-makers
do not encourage denials of coverage or service. Rather,
we encourage the delivery of appropriate health care
services. In addition, we train utilization review staff to
focus on the risks of underutilization and overutilization
of services. We do not encourage utilization-related
decisions that result in underutilization.
Admissions protocol
In the case of referred care, the admitting physician must
electronically submit or contact us for preadmission
precertification.* In the case of self-referred care, the
member must contact Aetna. Our precertification staff
also takes calls from hospital admissions personnel.
However, if the preadmission information isn’t complete,
we contact the admitting physician for clarification.
If the admission is precertified for surgical cases, we
assign a recommended length of stay (RLOS). This
determines when a review will start. For other cases,
we give specific guidelines with the admission
precertification. The RLOS determination is primarily
based on Milliman Care Guidelines
®
.
Notify us of hospital admissions within one
business day
We need notice of all inpatient admissions, including
those through the emergency department, within one
business day of the admission. If a patient is unable to
provide coverage information, you must contact us as
soon as you become aware of their Aetna coverage.
You must also explain any extenuating situation. You may
contact us by phone (call the number on the patient’s
member ID card) or through electronic data interchange
(EDI) through our provider portal.
All-products precertification list
Precertification* is the process of collecting information
before inpatient admissions and certain ambulatory
procedures and services.
The process includes:
• Confirmation of member eligibility
• Assessment of medical necessity
• Communicating a coverage decision to the treating
practitioner and/or member before the procedure,
service or supply
• Identifying members for pre-service discharge planning
• Identifying and registering members for covered
Aetna specialty programs, such as case management
and disease management, behavioral health, the
National Medical Excellence Program and the Aetna
Maternity Program
If we need to review the applicable medical records, we
may provide you with, and you need to agree to accept,
a precertification reference pending or tracking number.
The reference number is not an approval. You will be
notified once a coverage decision is made.
Medical records may be submitted using our provider portal.
You can find more information about our
precertification policy on our website.
You can also access an updated list of services requiring
precertification on our website.
Note: The term “precertification” refers to the utilization
review process used to determine whether the
requested service, procedure, prescription drug or
medical device meets our clinical criteria for coverage. It
does not mean precertification as defined by Texas law,
as a reliable representation of payment of care or
services to fully insured HMO and PPO members.
*Aetna Medicare members have access to a disease management program. It includes diabetes, coronary artery
disease, cerebrovascular disease and stroke and congestive heart failure. The program offers information and tools to
help these members better control their conditions. For information or to refer members, call the Member Services
number on the Aetna member ID card.
32
Member programs and resources
We offer many programs that some of your Aetna
patients may benefit from. If they qualify, there’s no extra
charge for them to join.
We review our members’ records to see who might be a
good candidate for some of these programs. If we feel a
member would benefit from joining, we reach out to
them directly. We inform them about the program and
invite them to participate. These programs are not a
substitute for regular visits to a physician. They are
meant to support the member’s physician. Through
some of these programs, we work directly with the
member. If that is the case, we apprise the physician of
the member’s health status as appropriate.
If you feel any of your Aetna patients would benefit
from one of these programs, let us know by calling the
Provider Contact Center. Your Aetna patients can also
contact us about these programs by calling the number
on their member ID cards.
Member programs
Care management
Our care management programs are designed to help
our members achieve their optimal health. Program
areas include:
• Disease management
• Case management
• End of life
• Transplant
• Women’s health and maternity
• Integrated clinical programs for behavioral health,
disability and pharmacy, as well as wellness programs
For more information, go to Aetna Health and Wellness.
Disease management
Our disease management program is designed to help
your patients work with their doctors. The goal is to
effectively manage ongoing health conditions and
improve outcomes.
Participants have access to nurses, who are available
to provide education and support. Participants may also
have access to some or all of the following:
• One-on-one work with with an Aetna nurse, who acts
as their “personal health coach”
• Personalized information about their current health
conditions and issues
• Educational information about multiple aspects of their
medical condition(s), treatment options and
medications
• Support in making lifestyle changes to achieve and
maintain optimal health
Our disease management programs are included in
many Aetna medical plans.* They’re also available to
self-funded plan sponsors that can include them in their
benefits offering. For additional information or to refer
your patients, call the Member Services number on the
member’s ID card. You can also find more information
on our public website.
Aetna
®
Healthy Lifestyle Coaching program
The Aetna Healthy Lifestyle Coaching program is a
comprehensive, motivational health coaching program.
It offers a suite of one-on-one telephonic health
coaching interventions, unlimited inbound calls, and
educational materials. The program is designed to help
participants change one or more modifiable lifestyle
behaviors, such as smoking and weight management.
* For benefits plans that require the issuance of referrals for specialist care in southern New Jersey, Pennsylvania,
Maryland, Virginia and the District of Columbia, the member should be directed to their PCP for referrals for
laboratory and radiology services.
33
Aetna
®
Lifestyle and Condition Coaching program
The Aetna Lifestyle and Condition Coaching program
offers members a comprehensive health strategy. It
provides lifestyle management, well-being and chronic
condition support through one unified holistic member
experience that blends personal and digital approaches
to support the member. The program is designed to
encourage sustained participation and help members:
• Form long-term healthy habits
• Reinforce and broaden existing healthy behaviors
• Improve lifestyle choices
• Successfully manage their chronic conditions
We deliver the program through a single-coach model
with the support of a multidisciplinary team. The
program engages members using diverse delivery
channels and resources. This holistic, unified approach
enables members to receive the right support they need,
when and where they need it.
Fitness programs for Aetna Medicare Advantage
members
Most individual Aetna Medicare Advantage plans offer
fitness benefits through a program called SilverSneakers
®
which is administered by Tivity Health. (SilverSneakers
isn’t available for two individual MA plans in Maryland.)
The fitness benefit is offered as a buy-up option for
most of our group Aetna Medicare Advantage plans.
However, the Medicare member should verify this in
their Evidence of Coverage document.
Medicare Members and providers can contact Member
Services to determine if the fitness benefit is available
and which program option is offered.
Women’s health programs
Our Women’s Health Policies and Procedures
Manual explains Aetna gynecologic and obstetric
programs and policies. It has information about our
Aetna Maternity Program.
Member resources
24-hour Nurse Line
The 24-hour Nurse Line puts members in touch with
registered nurses 24 hours a day, 7 days a week. The
nurses can provide information on thousands of health
issues, medical procedures and treatment options. They
can also offer members suggestions for communicating
more effectively with their doctors.
Institutes of Excellence™ network
Institutes of Excellence is our network of participating
facilities for the following services:
• Infertility services
• Solid organ, blood and marrow transplants
• Transplant-related services, including evaluation and
follow-up care
• Chimeric antigen receptor (CAR) T-cell therapy
Institutes of Quality
®
designation
Institutes of Quality is a designation facilities can achieve
for certain clinical services (for example, bariatric surgery
and selected orthopedic and cardiac procedures). We
base this designation on our evaluation of their processes
and outcomes (for example, readmission rates and
mortality rates) for these procedures.
Behavioral health
On Aetna.com, check out information on the
“Behavioral Health” page. There, you’ll find:
• Our Behavioral Health Provider Manual
• Archived issues of our Aetna Behavioral Health
newsletter for participating behavioral health
professionals
• Aetna Behavioral Health Programs overview
• Utilization Management and how we determine
coverage
*Referrals in Texas are only valid for 30 calendar days. After that time, another referral is needed.
34
Behavioral health access standards*
Service Time frame
Non-life-threatening emergency needs Within 6 hours
Urgent needs Within 48 hours of request
Routine office visits Within 10 days of request
Routine behavioral health follow-up care
• Within 5 weeks for behavioral health practitioners
who prescribe medications
• Within 3 weeks for behavioral health practitioners
who do not prescribe medications
Following inpatient hospital discharge
for a behavioral health condition
Within 7 days of the inpatient discharge
After-hours care • Behavioral health practitioners must have a reliable
24/7 live answering service or voice mail system.
• MDs are required to have a notification system for
call-backs or a designated practitioner backup.
• Non-MDs must have a message system that provides
24-hour contact information for a licensed behavioral
health care professional.
Aetna Depression in Primary Care Program
Depression often coexists with other serious medical
illnesses, such as heart disease, stroke, cancer, HIV/AIDS,
diabetes and Parkinson’s disease. Most people do not
seek treatment due to the perceived stigma associated
with depression. Many of those treated don’t receive
appropriate or continued treatment.
Our Aetna Depression in Primary Care Program is
designed to support the screening for and treatment
of depression at the primary care level.
Our program offers your primary care practice:
• A tool to screen for depression as well as monitor
response to treatment
• Reimbursement for depression screening and
follow-up monitoring
• Patient health questionnaire (PHQ-9) — specifically
developed for use in primary care
• PHQ-9 reimbursement**
To participate, you just need to be a participating primary
care provider, use the PHQ-9 tool to screen your patients
and submit claims with the following billing combination:
CPT code “96127” (brief emotional/behavioral assessment)
in conjunction with diagnosis code “Z13.89” (screening for
depression). To learn more, visit our Depression in
Primary Care Program homepage.
Screening, brief intervention and referral to
treatment (SBIRT) practice
SBIRT is an evidence-based practice used to identify,
reduce and prevent problematic use, abuse and
dependence on alcohol and illicit drugs. The Institute of
Medicine recommendation encourages the SBIRT model,
which calls for community-based screening for health
risk behaviors, including substance use.
*Unless state requirements are more stringent.
**State variations may exist.
35
We’ll reimburse you for screening patients for alcohol
and substance use disorder, provide brief intervention
and refer them to treatment. You can help increase the
adoption of the SBIRT process in your practice. The
patient must be 9 years of age or older and have Aetna
medical benefits to be eligible.
The SBIRT practice supports health care professionals
in all health care settings. Overall, our goal is to improve
both the quality of care for patients with alcohol and
substance abuse conditions, as well as outcomes for
patients, families and communities. You can visit our
Screening, Brief Intervention and Referral to
Treatment page to get started.
Download the app
The SBIRT app is now available as a free download
in the App Store for iOS devices. The app provides
evidence-based questions to screen for alcohol, drug
and tobacco use. If warranted, a screening tool is
provided to further evaluate the specific substance
use. The app also provides steps to complete a brief
intervention and/or referral to treatment for the patient
based on motivational interviewing.
Opioid Overdose Risk Screening program
In an effort to address the rising opioid epidemic,
we’ve implemented a screening program to identify
members at risk for opioid overdose. Our clinicians assess
cases involving opioid dependence. When they do, they
discuss the potential benefits of adding naloxone to the
member’s treatment plan as an intervention, in the event
of a relapse or future overdose.
Consider naloxone as part of the treatment plan for
patients at risk of an opioid overdose. Naloxone reverses
the effects of an opioid overdose. Providing naloxone kits
to laypeople reduces overdose deaths and is safe and
cost-effective. Other elements supporting this potentially
life-saving intervention include telling patients and their
family and support network about signs of overdose and
about administering naloxone.
Coverage of naloxone varies by individual plans and can
be verified by calling the number on the member ID card.
We’ll waive copays for the naloxone rescue medication
Narcan
®
for fully insured commercial members.
Pharmacy management and drug
formulary
Overview of the Pharmacy Plan Drug List
(formulary)
Providers should prescribe medications according to the
applicable drug formulary(ies). We may modify the drug
formulary(ies) from time to time.
Commercial plans
Our pharmacy benefits plans use a Pharmacy Plan
Drug List (formulary) to help maintain access to quality,
affordable prescription drug benefits for patients. Many
drugs, including drugs on the formulary, are subject to
manufacturer rebate arrangements between Aetna and
the manufacturers of those drugs.
Coverage is not limited to drugs on the list. In some
benefits plans, certain non-preferred drugs are excluded
from coverage, unless a medical exception is obtained.
These drugs are on our Formulary Exclusions List.
Note: Not all members with Aetna medical benefits have
Aetna pharmacy benefits.
Aetna Medicare Advantage plans
You can find the Medicare prescription drug formularies
at the following links:
• Individual MA-PD plan and PDP members
• Group MA-PD plan and PDP members
Requirements for Part B drugs
Under Medicare Advantage plans, some medically
administered Part B drugs, like injectables or biologics,
may have special requirements or coverage limits. One of
these special requirements or coverage limits is known
as step therapy, in which we require a trial of a preferred
drug to treat a medical condition before covering
another non-preferred drug. See the Aetna Part B
step therapy list.
*Aetna Medicare members have access to a disease management program. It includes diabetes, coronary artery
disease, cerebrovascular disease and stroke and congestive heart failure. The program offers information and tools to
help these members better control their conditions. For information or to refer members, call the Member Services
number on the Aetna member ID card.
36
CVS Caremark Mail Service Pharmacy™
CVS Caremark Mail Service Pharmacy is our mail-order
pharmacy. It provides maintenance medications for
chronic conditions, such as arthritis, asthma, diabetes, high
cholesterol, heart conditions and others. CVS Caremark
Mail Service Pharmacy can send members up to a
three-month supply of these medications, with their
physician’s approval.
With this service, your patients will enjoy the benefits
listed below:
• Convenience: Reorder only once every three months.
• Choice: Members can opt to receive order status alerts,
and can track orders and more by phone, email or text
message.
• Privacy: Prescriptions are discreetly packaged.
• Peace of mind: Pharmacists are available 24 hours a
day, every day, to answer members’ questions.
• Savings: Depending on the Aetna pharmacy benefits
plan, members may save money by using CVS Caremark
Mail Service Pharmacy. And standard shipping is always
available at no additional cost.
How your patients can learn more
To learn more, encourage members to visit our
Aetna member website. Once logged in, select “Aetna
Pharmacy” at the top of the page.
Aetna Specialty Pharmacy
®
mail-order pharmacy
Aetna Specialty Pharmacy is our specialty medication
pharmacy. It provides specialty medications including
injectable, infused and select oral therapies.
Specialty medications are unique because they treat
certain complex diseases. These conditions include
anemia, hepatitis C, multiple sclerosis, cancer, rheumatoid
arthritis and Crohn’s disease, among many others.
Specialty medications are often expensive and may not
be readily available at retail pharmacies. They may also
require refrigeration, special storage and handling, and
fast delivery.
Helping patients manage their therapies
Specialty medications usually carry risk for side effects and
risk that members may have trouble complying with their
prescribed therapy schedule. For these reasons, the use
of specialty medications must be consistently monitored.
With Aetna Specialty Pharmacy, your patients get
personal care plans and ongoing support:
• Nurses and pharmacists who specialize in each
patient’s needs are on call 24 hours a day.
• Care coordinators work with your patients to help
process orders quickly.
• Insurance and claims specialists help your patients
maximize their benefits plans.
• Service representatives reach out to set up refills.
Aetna Specialty Pharmacy offers other helpful services,
including:
• Free, secure delivery usually within 48 hours of
confirming each order, or later if you request
• Delivery to the patient’s home, your office or any other
location needed
• Package tracking to ensure prompt delivery of each order
• Self-injection training and education to help your patient
understand their condition and medication
Flexible payment options for out-of-pocket costs,
when necessary
This pertains to free injection supplies, such as needles,
syringes, alcohol swabs, adhesive bandages and sharps
containers for needle waste, if needed.
Treating many complex diseases
Many of these specialty medications are available only
through limited distribution networks. Aetna Specialty
Pharmacy also works hard to monitor the FDA’s pipeline
to get access to new specialty therapies. If Aetna Specialty
Pharmacy gets a prescription order for one of the few
therapies they don’t have access to, we respond without
delay. We will forward the prescription to the appropriate
contracted specialty pharmacy, along with a letter.
Ordering through Aetna Specialty Pharmacy is easy
• Print and complete a Medication Request Form.
• Fax it to: 1-866-FX-ASRX (1-866-329-2779).
• Or mail it to: Aetna Specialty Pharmacy, 503 Sunport
Lane, Orlando, FL 32809.
*Unless state requirements are more stringent.
37
Electronic prescribing
Physicians use e-prescribing technology to input
prescriptions through an electronic medical record (EMR)
using a tablet, smartphone or desktop computer.
Physicians can send orders electronically to the patient’s
pharmacy, eliminating the need for patients to physically
take the prescription to their pharmacy. Electronic
prescribing also helps:
• Reduce paperwork and result in faster, more accurate
information
• Simplify the prescribing process for physicians and
patients
• Reduce medication errors resulting from unreadable,
handwritten prescriptions
Aetna Pharmacy Management tries to integrate our
pharmacy information with our clinical support tools.
Our goal is to make insightful connections that can help
us identify and act on opportunities to help improve
member health.
Learn more about e-prescribing products and services.
Pharmacy clinical policy bulletins
The Aetna pharmacy clinical policy bulletins (PCPBs)
are used as a guide when determining coverage for
members with benefits plans that cover outpatient
prescription drugs. They also describe the medical
exception clinical coverage criteria for drugs on our:
• Formulary Exclusions List
• Precertification List
• Step-Therapy List
• Quantity Limits List
Precertification, step therapy and quantity
limits
Precertification
Most members with Aetna pharmacy benefits may have
a plan that includes precertification. These drugs require
an extra coverage review before they are covered.
Precertification is based on current medical findings,
FDA-approved manufacturer labeling information
and guidelines, and cost and manufacturer rebate
arrangements.
Visit our website to determine which medications
may require precertification. If you have questions,
call us at 1-800-Aetna-Rx (TTY: 711) or
1-800-238-6279(TTY: 711).
Step therapy
Some members may have a plan that includes step
therapy. With step therapy, certain drugs are not covered
unless members try one or more preferred alternatives
first. Step therapy is based on:
• Current medical findings
• U.S. Department of Food and Drug Administration
(FDA)-approved manufacturer labeling information
• FDA guidelines
• Cost and manufacturer rebate arrangements
If it is medically necessary, a member can get coverage of
a step therapy drug without trying a preferred alternative
first. In this case, a physician, patient or a person appointed
to manage the patient’s care must request coverage for
a step therapy drug as a medical exception. The drugs
requiring step therapy are subject to change. You’ll find
current step therapy requirements on our website. If you
have questions, call us at 1-800-Aetna Rx (TTY: 711) or
1-800-238-6279 (TTY: 711).
Quantity limits
We also limit coverage on the quantity of certain drugs.
Quantity limits are established using medical guidelines
and FDA-approved recommendations from drug
manufacturers. The quantity limits include the following:
• Dose efficiency edits: limits coverage of prescriptions to
one dose per day for drugs that are approved for
once-daily dosing.
• Maximum daily dose: a message is sent to the
pharmacy if a prescription is less than the minimum,
or higher than the maximum, allowed dose.
• Quantity limits over time: limits coverage of
prescriptions to a specific number of units in a defined
amount of time.
You, your patient or the person appointed to manage
the patient’s care may request a medical exception for
coverage of amounts over the allowed quantity. Contact
the Aetna Pharmacy Management Precertification Unit.
Refer to the Medical Exception and Precertification
information on how to access this unit.
38
Generic drugs
• Under Aetna commercial closed formulary plans,
generic drugs are generally covered. Those that aren’t
covered are on the Formulary Exclusions List.
• Many commercial formulary plans have a lower copay
for covered generic drugs. However, several generics
are considered nonpreferred and may be subject to
a higher, nonpreferred copay in some plans.
• To control health care costs, consider prescribing
preferred generic drugs when appropriate.
• In some plans, if the member or their physician
requests a brand-name drug when a generic drug is
available, the member may have to pay more. They have
to pay the difference in cost between the brand-name
drug and the generic drug, in addition to their copay.
• Many state laws encourage or require the pharmacy to
dispense generic drugs, if the prescriber permits.
Medical exception and precertification
You can ask for a medical exception for coverage of
drugs on the Formulary Exclusions List or the Step
Therapy List or request prior authorization or exceptions
to quantity limits. Physicians, patients or a person
appointed to manage the patient’s care can contact the
Aetna Pharmacy Management Precertification Unit.
To contact us, see the options below.
Phone Fax Online
Commercial 1-855-240-0535 (TTY: 711) 1-877-269-9916 —
Medicare part B 1-866-503-0857 (TTY: 711) 1-844-268-7263 —
Medicare part D 1-800-414-2386 (TTY: 711) 1-800-408-2386 On Aetna.com, see the
”Forms” section.
Commercial
precertification for
specialty drugs on the
Aetna National
Precertification List
1-866-752-7021 (TTY: 711) 1-888-267-3277 Go to Availity.com to
access this information.
Medicare
precertification for
specialty drugs on the
Aetna National
Precertification List
1-866-503-0857 (TTY: 711) 1-844-268-7263 Go to Availity.com to
access this information.
*Unless state requirements are more stringent.
**State variations may exist.
39
Performance programs
We use practitioner and provider performance data to
help improve the quality of service and clinical care
our members receive, if certain thresholds are met.
Accrediting agencies require that you let us use your
performance data for this purpose.
Quality, accreditation, review and reporting
activities
We expect providers to cooperate with any of our quality
activities, or any review of Aetna, a payer or a plan by:
• The National Committee for Quality Assurance (NCQA)
• The Utilization Review Accreditation Commission
(URAC) or other applicable accrediting organizations
• A state or federal agency with authority over Aetna and/
or a plan, as applicable
We expect our network providers to comply with our
reporting requirements. These include Healthcare
Effectiveness Data Information Set (HEDIS) and similar data
collection and reporting requirements.
Aexcel
®
network of specialist doctors
Aexcel is a designation within the Aetna Performance
Network. Aexcel designation helps distinguish physicians
in 12 specialty categories who have met certain clinical
performance and efficiency standards. Aexcel providers
are identified by a blue star.
We evaluate participating specialists in the 12 specialty
categories at least once every 2 years for Aexcel
designation. The evaluation process is made up of
4 key components:
• Case volume
• Clinical performance
• Efficiency
• Network adequacy
To find Aexcel physicians online, look for a blue star
next to their names. To learn more, log in to our
provider portal. Once on the site, go
to Aetna Support Center > Doing Business > Aexcel
Designation.
Patient-centered medical home (PCMH)
PCP practices can participate as a PCMH in two ways:
• Direct contract via an amendment to a physician
or group agreement
• Via the Aetna external PCMH recognition program
Each arrangement has its unique parts, but they all
generally include these two requirements:
• NCQA or other accepted organization’s PCMH
recognition, preferably Level 3 with a fully implemented
electronic medical record (EMR) process
• Adherence to the seven principles of PCMH (as
promoted by the PCPCC)
These two requirements cover many terms and standards,
such as:
• Case management
• Enhanced access for patients
• ePrescribing
• Measures tracking
• Patient registries
Our PCMH Recognition programs are designed to:
• Meet the triple aim of improved efficiencies, clinical
outcomes and patient satisfaction
• Help establish a sufficient amount of PCMH sites to
enable us to offer the advantages of a benefits plan
featuring PCMHs to plan sponsors. Under this type of
plan, members would choose a PCMH PCP practice for
their primary care services
A direct contract is available in all markets to all providers
that include PCPs and is executed via a signed amendment
to the provider’s current participation agreement. The
external PCMH recognition program is only available in
markets that Aetna decides to implement. These are
currently:
• The states of Arizona, Colorado, Connecticut, Delaware,
Maryland, Massachusetts, New Jersey, New York,
Virginia, Washington and West Virginia
40
• The city of Tampa, Florida
• The cities of Cleveland and Columbus, Ohio
Physician pay for performance (P4P)
Participation is through a direct contract. It’s available
in all markets to all providers that include PCPs.
It’s executed via a signed amendment to the provider’s
current participation agreement.
Our nationally available Physician Performance Incentive
programs apply the strengths of our data aggregation
and national data repository resources to local-market
initiatives. This allows for customized measures and
goals. Annual goals are:
• Negotiated agreements between the provider group
and Aetna
• Based on market position and previous-year
measurements
We provide detailed information on each individual
physician’s results on each measure.
Our physician performance incentive programs identify
and target areas of opportunity for quality improvement.
The objective is to help improve the overall quality, safety
and cost efficiency of health care. These programs set
targets for improvements and deliver performance
measurement results for:
• Independent practice associations (IPAs)
• Physician-hospital organizations (PHOs)
• Physician groups
We incorporate group and physician-level data into
our online and other tools. This provides actionable,
patient-level information to physicians. Physicians earn
reward payments only when they either improve toward
their targeted performance results or maintain their
high-performing levels of achievement.
We annually reset target goals and, in some cases, add
and/or drop measures. In most programs, physicians are
not paid for this component of their compensation until
we have measured and compared their performance to
targets. As a result, performance payments are not
included in initial claims payments.
More broadly, we believe that performance incentive
program success requires:
• A clear and specific understanding between payers
and providers on the parameters of the program’s
measurements, incentive opportunities and targets
• National consensus measures
• A focus on continuous quality improvement
• A commitment to retire measures after there have
been several periods of top-level performance (for
example, 95% and above) and replace them with new
measures that give physicians new opportunities for
improvement
• Collaboration to identify new sources of actionable
information, and creative ways to encourage and engage
with physicians and physician groups effectively
• A commitment across all commercial payers to include
performance incentives in the overall reimbursement
strategy. We recognize that when physicians improve
their practices, all patients benefit.
Clinical medical management
Clinical practice and preventive service
guidelines
Evidence-based clinical practice and preventive services
guidelines from nationally recognized sources promote
consistent application of evidence-based treatment
methodologies. This helps to provide the right care at the
right time. For this reason, we make these guidelines available
to our network providers to help improve health care.
These guidelines are provided for informational purposes
only. They aren’t meant to direct individual treatment
decisions. All patient care and related decisions are the
sole responsibility of providers. These guidelines don’t
dictate or control a provider’s clinical judgment regarding
the appropriate treatment of a patient in any given case.
Evidence-based guidelines can be found on various
nationally recognized sources. Here are links to some
of those sources.
41
Clinical practice guidelines
• Agency for Healthcare Research and Quality
• American College of Cardiology/American Heart
Association
• American Diabetes Association
• American Psychiatric Association
• National Heart, Lung and Blood Institute
Behavioral health clinical practice guidelines
• American Academy of Pediatrics (AAP) Guideline
for the Diagnosis, Evaluation, and Treatment of
Attention-Deficit/Hyperactivity Disorder in
Children and Adolescents
• American Psychiatric Association (APA) Guideline
for the Treatment of Patients with Major
Depressive Disorder
• American Psychiatric Association (APA) Guideline
for the Pharmacological Treatment of Patients
with Alcohol Use Disorder
• American Psychiatric Association (APA) Guideline
for the Treatment of Patients with Substance Use
Disorders
• Centers for Disease Control (CDC) Guideline for
Prescribing Opioids for Chronic Pain
Preventive services guidelines
• Centers for Disease Control and Prevention
Immunization Schedules
• U.S. Preventive Services Task Force
Case management
According to the Case Management Society of America’s
website, “Case Management is a collaborative process of
assessment, planning, facilitation, care coordination,
evaluation and advocacy for options and services to meet
an individual’s and family’s comprehensive health needs
through communication and available resources to
promote patient safety, quality of care, and cost effective
outcomes.”
1
Case management is a standard component
of most Aetna medical plans.
The foundation of the case management program is
evidence-based medical literature and clinical practice
guidelines. There are both automated and manual
processes to identify members for case management
through a variety of methods.
Case managers coordinate care and services for complex
case management members who require the extensive
use of resources as a result of a critical event or
diagnosis. Case managers assist these members with
navigating the health care system in order to facilitate
the appropriate delivery of care and services.
Case management screening occurs before member
outreach in order to determine member eligibility and the
appropriateness of case management services. We
welcome referrals from treating physicians to our case
management program. You can submit a referral through
the toll-free phone number on the member ID card.
Once we decide that a member is right for case
management and the member or caregiver agrees to it,
we make an individualized plan.
Clinical care management staff, in coordination with
the attending practitioner, member, or member
representative, develop an individualized case
management plan based upon an assessment of the
member’s needs.The case management plan includes
documentation of prioritized goals, which are specific,
measurable and time-bound, and reflective of issues that
the member assessment identifies. Targeting the case
manager’s activities helps to identify issues, remove
barriers to care, and facilitate the achievement of the
member’s health goals.
There is regular review, monitoring and evaluation of
the progress in meeting case management plan goals
and objectives for each member active in case
management. Case closure occurs once there is
resolution of all member issues and barriers and/or the
member meets case closure criteria.
42
Coordination of care
Importance of collaboration
We monitor and try to improve coordination and
collaboration between treating providers of care. Results
from our annual Physician Practice surveys have shown
that physicians continue to be concerned that they do
not regularly receive reports about their patients’ ongoing
evaluation and care from other practitioners and facilities.
These include medical specialists, behavioral health
practitioners, skilled nursing facilities, home health
agencies, surgical centers or hospitals. The increased
focus on patient safety in the medical community also
highlights the critical nature of improving collaboration
between treatment providers.
Sharing patient information
Increased treatment compliance and improved outcomes
have been attributed, in part, to collaboration between
providers.
2
In addition, the quality of communication is
rated as an important factor considered by primary care
physicians when choosing a specialist to whom they can
refer their patients.
3
To this end, we strongly encourage you to send
progress notes and discharge summaries to your
patients’ other treating practitioners.
2
Forms are
available on our public website at Aetna.com and
include the following:
• The Physician Communication Form and the
Specialist Consultant Report. These can be used to
share information between a primary care physician and
specialty care physicians in order to document a
patient’s diagnosis, medications, procedures and status.
• The Behavioral Health/Medical Provider
Communication Form. This helps behavioral health
providers share information about a patient’s treatment
plan with primary care physicians. Providers can use
the form to pass on detailed information about a
patient’s diagnosis, medications, risks and concerns.
Accessing communication forms
You can access these forms on our public website.
We appreciate your efforts to close the communication
gap between specialists, facilities and primary care
physicians and promote improved patient care and safety.
Transition of care
Transition of care provides a temporary bridge for
members at the time of plan enrollment or renewal.
Members in an active course of covered treatment that
meets clinical coverage criteria/guidelines with a treating
provider may be eligible for transition of care coverage
consideration. The treating provider must fall under one
of these categories:
• Is not a contracted provider in the member’s plan
• Is not a practitioner designated for inclusion within a
tiered network (Aetna Performance Network) or Aexcel
®
specialty categories when a specific practitioner or
provider network is applicable to the member’s plan
• Is not included within a plan sponsor-specific network
Additionally, the treating provider must be an individual
practitioner (for example, a specialist, physical therapist,
speech therapist) or home care agency in order to be
eligible for the transition of care process
Transition of care does not apply to nonparticipating
durable medical equipment (DME) vendors or pharmacy
vendors. Transition of care does not apply to
nonparticipating facilities, with the exception of facilities
in which:
• The Aetna contract has terminated (for reasons other
than quality issues)
• A treating participating practitioner temporarily has
privileges only at the nonparticipating facility
The transition-of-care process applies to all benefits
plans except Traditional Choice
®
and Aetna Medicare
Advantage PPO ESA (Extended Service Area) plans. It is
also limited to a fixed period of time. Transition of care
also applies to members who are in an active course of
covered treatment when a physician or other health care
professional terminates participation in the Aetna network.
An “active course of treatment” is defined as a program
of planned services that:
• Starts on the date a physician or other health care
professional first renders a service to correct or treat
the diagnosed condition
• Covers a defined number of services or period
of treatment
• Includes a qualifying situation (for example, a surgical
follow up)
43
The four steps for requesting transition of care
1. The member asks for a Transition Coverage Request
Form from Member Services or their employer. The
member completes the form with help, as needed,
from the nonparticipating treating physician.
2. The member or nonparticipating treating physician
faxes the completed form to the Aetna fax number
on the form.
3. We review the information. When necessary, an
Aetna Medical Director evaluates the treatment
program. The director may also contact the
treating physician or health care professional.
4. We send a letter about the coverage decision to
the member and the nonparticipating treating
physician or health care professional. If coverage
is approved, the letter also includes the length of
time the transition benefits apply. We also send
a letter to the member’s primary care physician,
as applicable.
Complaints and appeals
We have a formal complaint and appeal policy* for
physicians, health care professionals and facilities. The
complaint and appeal process has one level of appeal.
Physician, health care professional and facility appeals
involve payment decisions (claims). A provider may also
appeal pre-service or concurrent medical-necessity
decisions. However, those appeals will be handled
through the member appeal process.
Note: The process may vary due to state-specific
requirements. For more information on complaints or
appeals, contact your local Aetna office.
Physician and health care professional post-service
appeals may either be on the provider’s behalf or on
the member’s behalf. An appeal is not considered to
be on behalf of the member unless it:
• Explicitly says “on behalf of the member”
• Includes written authorization from the member that
was submitted by the physician or health professional
To learn more, see our disputes and appeal process.
In accordance with CMS requirements, we have a formal
process for Aetna Medicare Advantage** plan provider
dispute resolution for non-contracted providers.
44
Medicare
Aetna Medicare Advantage plans
Below is a summary of how our Aetna Medicare
Advantage plans work with primary care physician (PCP)
selection, referrals and out-of-network benefits.
Aetna Medicare Health Maintenance Organization
(HMO) plans and Aetna Medicare HMO Prime plans
Patients must choose and use a participating PCP.
Patients must get referrals from their PCP before getting
nonemergency care from other participating providers.
Exception: Behavioral health routine outpatient visits.
Members are required to receive all covered services
— with the exception of emergent or urgently needed
services and out-of-area renaldialysis — through Aetna
Medicare Advantage network providers. These Aetna
Medicare Advantage HMO plans require members to
select a participating PCP. If the member doesn’t select a
PCP, one will be auto assigned. Members may change the
auto-assignment by contacting Aetna.
Aetna Medicare HMO plans with open access
• Patients are encouraged, but not required, to choose
and use a participating PCP.
• PCP referrals are not required.
• Services received outside of the Aetna participating
provider network are not covered — except for
emergency, out-of-area urgent care, or out-of-area
renal dialysis — unless approved by us in advance of
receiving services.
Aetna Medicare Preferred Provider Organization
(PPO) plans and Aetna Medicare PPO Prime plans
• Patients are encouraged, but not required, to choose
and use a participating PCP.
• PCP referrals are not required.
• Patients receiving covered services from a
nonparticipating provider are subject to out-of-network
deductibles, coinsurance, and potential balance billing.
Aetna Medicare Advantage plans (HMO and PPO)
Aetna contracts with the Centers for Medicare & Medicaid
Services (CMS) to offer Aetna Medicare Advantage plans.
As such, we’re considered a Medicare Advantage
organization (MAO). All MA plans are required to offer
Medicare Parts A and B medical benefits and to follow
CMS’ national and local coverage decisions. MA plans
may also offer Medicare Part D benefits (MA-PD). We
offer both individual and employer group-sponsored
MA products. The Aetna Medicare Advantage Health
Maintenance Organization (HMO) plans are available
in select counties and states throughout the country.
Aetna Medicare Advantage Preferred Provider
Organization (PPO) plans are available to individuals in
select counties and states throughout the country and for
employer groups in all 50 states, plus the District of Columbia.
Go the Medicare page on Aetna.com for specific Aetna
Medicare Advantage plan information.
Individuals may choose from several Aetna Medicare
Advantage plans, depending on their location, budget
and needs. Go to AetnaMedicare.com to see the plans
available within a specific geographic area.
Aetna Medicare Advantage HMO plan Members
are required to receive all covered services, with the
exception of emergent or urgently needed services and
out-of-area renal dialysis, through Aetna Medicare
Advantage network providers. The Aetna Medicare
Advantage Plan (HMO) requires members to select a
participating PCP and, except for those benefits
described in the member’s plan documents as
direct-access benefits and emergency or urgent care,
members must have a referral from their PCP to obtain
covered specialty services or care in a facility. If the
member doesn’t select a PCP, one will be automatically
assigned. If a member wants to change to another
in-network PCP instead of keeping the one who was
automatically assigned, the member can contact Aetna.
In select service areas, the individual Aetna Medicare
Advantage Plan (HMO) includes an open-access feature
that does not require PCP selection or referrals for
in-network covered services. Some employer group
plans may also offer this feature.
Aetna Medicare Advantage PPO plan Members are
not required to select a PCP or obtain a referral in order to
obtain services from participating providers. Generally,
members who select a PCP are responsible to pay the PCP
copayment for covered services received from their
designated PCP. Aetna Medicare Advantage Plan (PPO)
members also have the option to receive covered services
from any nonparticipating provider for covered services
without a referral. If exercising this option, the member is
responsible for the cost of his or her out-of-network
medical expenses in accordance with their plan.
45
In addition, CMS provides an Employee Group Waiver
Plan that permits an MAO to extend enrollment to all
retirees of an employer group. This is permitted even
if some of the retirees reside in a service area where
Aetna does not offer a provider network that meets
CMS network requirements (“Extended Service Area”).
To use this waiver, at least 51% of members enrolled in the
employer group Medicare Advantage (MA) plan must
reside in a service area where Aetna offers a provider
network that meets CMS requirements. And members
who reside in an Extended Service Area must be permitted
to obtain all covered services from nonparticipating
providers at the in-network level of cost sharing.
Home assessment program
As part of our ongoing quality improvement efforts, we
periodically offer in-home health assessments to our
Aetna Medicare Advantage members. It’s possible your
patients may be asked to participate in this no-additional-
cost, comprehensive assessment. It is voluntary,
performed in the patient’s home by a licensed provider,
and allows you access to information about your patient’s
home condition and environment. If one of your patients
is selected to participate in this program, a summary of
the completed assessment will be mailed to you.
We’ll use information from the assessment to identify
care management programs which may benefit the
member. If you have questions about the home
assessment program, contact your local provider
relations representative for more information.
Quality improvement program
An annual Chronic Care Improvement Program (CCIP) is
implemented in accordance with CMS requirements. It is
designed and conducted to coordinate care, promote
quality and help improve member satisfaction.
The goal of the CCIP is to promote effective management
of chronic disease and improve health outcomes and
quality of care. Programs are available to support your
patients and to help them make healthy lifestyle choices.
Medicare prescription drug plan
We administer a stand-alone prescription drug plan (PDP)
portfolio of products referred to as SilverScript. There are
two different PDP plan options available to individuals on a
national basis. Medicare prescription drug benefits are
also offered to individuals through our MA plans that
include Medicare prescription drug coverage (MA-PD
plans) in select service areas. In addition, we offer
Medicare prescription drug coverage through PDPs and
MA-PD plans to employer groups nationwide.
MA-PD plans and PDPs must meet applicable benefits
requirements under the Medicare Part D program and,
as of 2020, at a minimum, these plans must contain the
following provisions.
• Deductible: not to exceed $435 for 2020.
• Coverage gap: once a member reaches $4,020 in
covered Medicare Part D drug expenses, he or she
will pay no more than 25% for covered generics and
25% for covered brand drugs, including a manufacturer
discount of up to 70% off covered-brand drug costs
until reaching the True Out-of-Pocket (TrOOP) threshold
of $6,350. Most individual and group PDP and MA-PD
plans provide supplemental gap coverage.
Note: The previous description is not applicable to
members who qualify for Low-Income Subsidy assistance.
• Catastrophic coverage level: for 2020, once a member
reaches $6,350.00 in TrOOP costs for covered Part D
drugs, the member’s maximum cost sharing for covered
Part D drugs will be the greater of 5% or $3.60 for generic
drugs (or those prescription drugs that are treated like
generic), or $8.95 for all other prescription drugs.
• Quantity limits, step therapy and precertification
requirements apply to certain prescription drugs.
• Formulary: the Aetna Medicare prescription drug
formularies (also known as the “Aetna Medicare
Preferred Drug List”) differ from the formularies
applicable to Aetna commercial pharmacy plans.
Go to AetnaMedicare.com/formulary to see a list
Medicare prescription drug formularies.
Group MA-PD Plan and PDP members: visit our retiree
plans website at AetnaRetireePlans.com, t hen select
“Manage your prescription drugs.”
Note: All formularies applicable to MA-PD plans and
PDPs are reviewed and approved by CMS.
Transition-of-coverage (TOC) policy
CMS requires Part D plan sponsors, like Aetna, to have an
appropriate TOC process. Members who are taking Part
D drugs that are not on the plan’s formulary or that are
subject to utilization management requirements can get
a transition supply of their drug in certain circumstances.
This gives members the opportunity to work with their
1
Case Management Society of America. What Is A Case Manager? CMSA. 2017. Available at:
CMSA.org/who-we-are/what-is-a-case-manager/. Accessed on March 30, 2020.
46
doctors to complete a successful transition and avoid
disruption in their respective treatments.
Aetna Medicare has established a TOC process in
accordance with CMS requirements that applies to new
members as well as current members who remain
enrolled in their Aetna Medicare plan from one plan year
to the next.
The following is a summary of the key features of Aetna
Medicare’s TOC process.
Newly enrolled members who are taking a Part D drug
that is not on the Aetna Medicare formulary, or is subject
to a utilization management requirement or limitation
(such as step therapy, pre-authorization or a quantity
limit), are entitled to receive a maximum of a 30-day supply
of the Part D drug within the first 90 days of their enrollment.
(The period of time in which they are entitled to receive the
transition supply is called their “transition period.”)
Existing members who renew their Aetna Medicare
coverage and are taking a Part D drug that is removed
from the formulary, or is subject to a new utilization
requirement or limitation at the beginning of the new
plan year, are entitled to receive a maximum 30-day
supply during their transition period. For existing
members who renew their Aetna Medicare coverage
from one year to the next, their transition period is the
first 90 days of the new plan year.
Whether an individual is a new or renewing member,
if the member’s initial prescription is for less than the
full transition amount (30 days), the member can get
multiple fills up to the 30-day supply. If a member lives
in a long-term care facility and is entitled to a transition
supply, Aetna will cover a 31-day supply (unless the
prescription is for fewer days).
Members may also be entitled to receive a transition fill
outside of their transition period in certain circumstances.
We send a TOC notice to members via first-class mail
within 3 business days from the date the transition fill
claim is processed. The letter:
• Notifies members that the transition fill was a
temporary supply
• Describes the options available to the member if the
drug for which they received the transition fill is not on
the formulary or is subject to a utilization management
requirement or restriction (including changing to a
therapeutic alternative, or seeking an exception or prior
authorization, as appropriate)
• Describes the procedures for requesting an exception
or prior authorization
• Encourages members to work with their respective
doctors to achieve a successful transition so they can
continue to receive coverage for the drugs they need
A duplicate copy of the notice is sent to the prescribing
physician.
Go to AetnaMedicare.com/documents/
individual/2020/formularies/TOC_2020_aetna_
part_D_transition_policy.pdf to view the transition
rules for our Medicare prescription drug process.
Additional prescription drug plan information
• Days supply: Generally, a 1-month prescription may
be filled for up to a 30-day supply. A member may
obtain up to a 3-month (90-day) supply of maintenance
medications from either a participating retail pharmacy
or through a participating mail-order vendor.
• Mail-order drug option: A member may obtain up to
a 90-day supply of maintenance medications from our
preferred CVS Caremark Mail Service Pharmacy
mail-order pharmacy.
Specialty pharmacies fill high-cost specialty medications
that require special handling. Although specialty
pharmacies may deliver covered medications through
the mail, they are not considered “mail-order
pharmacies.” Therefore, most specialty drugs are not
available at the mail-order cost share. In 2014, CMS
instituted a feature that allows PDP and MA-PD plan
members in some instances to pay prorated cost sharing
for prescriptions written for less than a 30-day supply.
For example, prorated cost sharing may apply when an
initial prescription is written for a short supply to ensure
the member can tolerate the drug, or when a member
wishes to synchronize their prescriptions to fill on the
same day. However, limitations apply to this plan feature.
For example, prepackaged drugs cannot be broken, and
this plan feature does not apply to antibiotics and some
other drugs.
2
G
rey N, Maljanian R, Staff I, Cruzmarino de Aponte M. Improving care of diabetic patients through a collaborative care
model. Conn Med. Jan 2002;66(1), 7-11. Felker BL, Chaney E, Rubenstein LV, Bonner LM, Yano EM, Parker LE, Worley LL,
Sherman SE, Ober S. Developing effective collaboration between primary care and mental health providers. Prim Care
Companion J Clin Psychiatry. 2006;8(1), 12-16. Dawson S. Interprofessional working: communication, collaboration ...
perspiration! Int J Palliat Nurs. Oct. 2007;13(10), 502-5.
3
Kinchen KS, Cooper LA, Levine D, Wang NY, Powe NR. Referral of patients to specialists: factors affecting choice of
specialist by primary care physicians. Annuals of Family Medicine. May/June 2004;2(3), 245-252.
47
Preferred pharmacies
Most of our plans give members access to our preferred
pharmacy network.
Our members generally pay less when they fill their
prescription at one of our preferred pharmacies.
All of our network pharmacies must meet strict discount
standards. But preferred pharmacies offer us even bigger
discounts. And we pass those discounts on to our
members, in the form of lower-cost sharing.
Preferred pharmacies are identified with a circled “P”
in our directories. Go to AetnaMedicare.com/
findpharmacy to search online.
Part D drug rules
Here are three general rules that apply to Medicare
Part D drug prescription coverage:
1. Medicare Part D cannot provide coverage for a
drug that would be covered under Medicare Part A
or Part B.
2. Medicare Part D cannot provide coverage for a
drug that is purchased and/or consumed outside
the United States and its territories.
3. Medicare Part D usually cannot provide coverage
for “off-label use.” Generally, coverage for “off-label
use” is allowed under Medicare Part D only when
the use is supported by the following reference
books:
• The American Hospital Formulary Service Drug
Information
• The DRUGDEX Information System
• The United States Pharmacopeia-Drug
Information (USP DI) or its successor
Also, by law, the following categories of drugs are not
covered by Medicare Part D unless enhanced drug
coverage is included or offered under a particular
Medicare Part D plan or benefit:
• Nonprescription drugs (also called over-the-counter
drugs)
• Drugs when used to promote fertility
• Drugs when used for the relief of cough or cold symptoms
• Drugs when used for cosmetic purposes or to promote
hair growth
• Prescription vitamins and mineral products, except
prenatal vitamins and fluoride preparations
• Drugs when used for the treatment of sexual or erectile
dysfunction, such as Viagra, Cialis, Levitra and Caverject
• Drugs used for the treatment of anorexia, weight loss
or weight gain
• Outpatient drugs that the manufacturer is selling, only
if the associated tests or monitoring services are also
purchased from the manufacturer
The amount a member with Medicare Part D coverage
pays when filling prescriptions for these drugs does not
count towards the plan deductible, initial coverage limit
or qualifying for the Catastrophic Coverage Stage. Also,
those eligible for the Low-Income Subsidy will not pay the
plan cost-share in place of their subsidized cost-sharing.
Note: Most injectable medications and oral drugs not
covered under Medicare Part B will be considered
Medicare Part D drugs, but coverage will be determined
by the formulary. Precertification is required for
Medicare Part B situational drugs. If you have questions
regarding whether a medication is covered under
Medicare Part B versus Medicare Part D, contact the
Aetna Pharmacy Management Precertification unit at
1-800-414-2386(TTY: 711) for assistance.
Home infusion
The following provisions only apply to providers who
dispense home infusion drugs that are covered under
Medicare Part D to Medicare members (and the
Medicare member has MA-PD coverage):
• The provider will be paid clean claims within 30 days,
and the provider will be reimbursed at the rates agreed
to by the provider and Aetna.
• Updates to prescription drug pricing used for payment
will occur no less frequently than once every seven
days, beginning with an initial update on January 1 of
each year, to accurately reflect the market price of
acquiring the home infusion drug.
• The provider will submit claims for home infusion drugs
whenever the Medicare member’s ID card is presented
(or is on file), unless the Medicare member expressly
requests otherwise.
• The provider must submit claims for home infusion drugs
by means of a point-of-service claims adjudication system.
• The provider must provide Medicare members with
access to the negotiated prices.
• The provider must apply the correct cost-sharing
amount to the Medicare member, as indicated by Aetna.
• The provider must inform the Medicare member of any
difference between the price of the home infusion drug
being dispensed and the price of the lowest-priced
generic version, unless the home infusion drug being
dispensed is the lowest-priced generic version.
48
• Before dispensing, the provider must ensure that the
professional services and ancillary supplies necessary
for home infusion drugs are in place.
• The provider must provide delivery of home infusion
drugs within 24 hours of Medicare member’s discharge
from an acute setting, unless prescribed later.
• The provider must submit claims for equipment,
supplies and professional services associated with
dispensed home infusion drugs for Medicare members
covered by Medicare Part C.
Additional Aetna Medicare Advantage information
As outlined in Medicare laws, rules and regulations,
physicians and health care professionals (and their
employees, independent contractors and subcontractors)
contracted with an Aetna Medicare Advantage
organization (“contracted providers”) must comply with
various requirements. Refer to your Aetna contract for
further information regarding these Medicare contractual
requirements. What follows is a general summary of some
Medicare requirements that apply to contracted providers.
Physician–member communications policy
Our contracts with participating providers do not contain
“gag clauses.” Nothing about the contract prevents the
physicians or other health care professionals from
discussing issues openly with their patients. We include
language in our contracts to promote open physician–
member communication. The objective is to give our
members the comfort of knowing their physicians and
other health care professionals have the right and the
obligation to speak freely with them.
We encourage providers to discuss with their patients:
• Pertinent details regarding the diagnosis of their
conditions
• The nature and purpose of any recommended procedure
• The potential risks and benefits of any recommended
treatment
• Any reasonable alternatives to such recommended
treatment
Demographic data quarterly attestation
The Centers for Medicare & Medicaid Services (CMS)
requires every Medicare Advantage Organization (MAO)
to perform quarterly outreach to every MAO-contracted
provider and request validation of their demographic
information listed in our search tool. We use vendors
(currently the Council for Affordable Quality Healthcare
®
and Availity
®
) to make this outreach each quarter, and
you are obligated, as an Aetna Medicare Advantage
provider, to comply with this validation.
If you move your office or change your phone number
or other demographic information, you should go to the
website for our vendor and update your profile within
seven days of the change. Do not wait for the quarterly
attestation process, and do not call or fax the information
to Aetna. We will get the update from the vendor and
process it accordingly.
It’s important that you cooperate fully with the validation
and attestation requests from our vendors within the
allotted time frame. To do so, just sign in to their website
and complete the attestation questions about your
demographic information. We take this compliance
obligation very seriously and will take action against
providers who refuse to cooperate. This action can
include the suppression and, ultimately, the termination
of participation in our Aetna Medicare Advantage plans.
The Centers for Medicare and Medicaid Services (CMS) is
also encouraging health plans and providers to use the
National Plan and Provider Enumeration System (NPPES)
as a resource to improve data accuracy. We join with the
CMS to remind providers to review, update, and certify
that their data is current in NPPES. Accurate provider
directories help Medicare beneficiaries identify and locate
providers and make health plan choices.
Collecting all Aetna Medicare Advantage plan
member cost sharing
CMS reviews and approves all Medicare Advantage (MA)
benefits packages. The statutes, regulations, policy
guidelines and requirements in the Medicare Managed
Care Manual and other CMS instructions are the basis
for these reviews and approvals. To comply, MA
organizations must be sure that their MA plans do not
discriminate in the delivery of health care services,
including source of payment.
The rules regarding collection of Medicare beneficiary
cost-share amounts applicable in traditional Medicare apply
to Aetna Medicare Advantage as well. Therefore, providers
must collect all applicable cost-share amounts from Aetna
Medicare Advantage plan members. To waive the cost
share is a direct violation of federal laws and regulations.
This action puts Aetna and your compliance at risk.
Access to facilities and records
Medicare laws, rules and regulations require that
contracted providers retain and make available all
records pertaining to any aspect of services furnished
to MA plan members or their contract with the MAO for
49
inspection, evaluation and audit. Providers are required
to hold these records for whichever of the following time
periods is longest:
• A period of 10 years from the end of the contract
period of any Aetna Medicare contract.
• The date the Department of Health and Human
Services or the Comptroller General or their designees
complete an audit.
• The period required under applicable laws, rules
and regulations.
Access to services
We have established programs and procedures to:
• Identify members with complex or serious medical
conditions
• Work in conjunction with the member’s physician, who
is responsible for directing and managing their patients’
care, assessing those conditions, and using medical
procedures to diagnose and monitor patients on an
ongoing basis
• Establish a treatment plan with an adequate number
of direct-access visits to specialists (that is, no prior
authorization required) to implement the treatment plan
In addition, as provided in applicable laws, rules and
regulations, contracted providers are prohibited from
discriminating against any Medicare member based on
health status. Therefore, providers contracted with us
are required to make services available in a culturally
competent manner to all MA plan members. This
includes those with limited English proficiency or reading
skills, diverse cultural and ethnic backgrounds, and
physical or mental disabilities. In turn, we maintain
procedures to inform members with specific health care
needs of follow-up care and provide training in self-care,
as necessary.
Medicare Outpatient Observation Notice
(MOON) requirement
All participating hospitals and critical access hospitals
(CAHs) must adhere to the provisions of the MOON
Notice Act developed by CMS. Under this act, hospitals
and CAHs must deliver a MOON to any member,
including Medicare Advantage members, who receives
observation services as an outpatient for more than 24
hours. The MOON must be provided to members no
later than 36 hours after services begin. Go to
CMS.gov/medicare/medicare-general-information/
bni/index to find the notice and the accompanying
instructions.
Medicare Medical Loss Ratio (MLR) requirements
Congress, under the Affordable Care Act, amended the
MA program provisions in the Social Security Act to
require MAOs to achieve an 85% MLR, beginning with
contract year 2014. CMS issued regulations to implement
these MLR requirements that include new maintenance
and access to records obligations.
These new requirements apply to any provider who:
• Is contracted with an MAO to participate in their
Medicare network
• Retains medical/drug cost data that the MAO uses to
calculate Medicare MLRs for which the MAO does not
have independent access
Under these new regulations, MAOs “are required to
maintain evidence of the amounts reported to CMS and
to validate all data necessary to calculate MLRs.” This
requirement exists for 10 years from the date that such
calculations were reported to CMS.
Additionally, the MAO “must require any third-party
vendor supplying drug or medical cost contracting and
claim adjudication services” to provide the MAO with
“all underlying data associated with MLR reporting …
regardless of current contractual limitations.” If this MA
regulation is applicable to a participating provider, the
provider is required to do both of the following:
• Ensure that they are retaining such data for the
requisite time period (11 years from the CMS MLR
reporting date, not the termination of the CMS
contract, as referenced in existing MA regulations).
• Preserve the MAO’s and government’s ability to obtain
data and records, as necessary, to satisfy any
government information request during the
11-year period.
Advance directives
Our contracted providers must document in a prominent
place in an MA plan member’s medical record whether
the member has executed an advance directive. Refer
*State variations may exist.
** Aetna Medicare Advantage plans must comply with CMS requirements and time frames when processing appeals
and grievances received from Aetna Medicare Advantage plan members. Refer to the “Medicare” section, which
begins on page 45 of this manual, for further information.
50
to the Member Rights and Responsibilities policy for
more information on advance directives.
MA Organization Determination (OD) process
Medicare beneficiaries enrolled in MA plans are entitled
to request an OD, which is a decision or determination
concerning the rights of the member with regard to
services covered by Medicare and/or Aetna, and any
decision/determination concerning the following items:
• Reimbursement for coverage of emergency, urgently
needed services or post-stabilization care.
• Payment for any other health services furnished by a
provider or supplier other than the organization that the
member believes are Medicare covered. Or, if not covered
by Original Medicare, should have been furnished,
arranged for or reimbursed by the organization.
• Denial of coverage of an item or service the member
has not received but believes should be covered.
• Discontinuation of coverage of a service, if the member
disagrees with the determination that the coverage is
no longer medically necessary.
Members can request an expedited or standard
organization determination decision. We will review
and process the request in accordance with the CMS
requirements and time frames. If the member’s request is
denied, the member may exercise his or her appeal rights.
Ban of Advance Beneficiary Notice of Noncoverage
(ABN) for Medicare Advantage (MA)
Provider organizations should be aware that an ABN is
not a valid form of denial notification for a MA member.
ABNs, sometimes referred to as “waivers,” are used in the
Original Medicare program. CMS prohibits use of ABNs
for members enrolled in a Medicare Advantage plan.
Therefore, ABNs cannot be used for patients enrolled in
Aetna Medicare Advantage plans.
As a provider who has elected to participate in the
Medicare program, you should understand which
services are covered by Original Medicare and which
are not. Aetna Medicare Advantage plans are required
to cover everything that Original Medicare covers and
in some instances may provide coverage that is more
generous or otherwise goes beyond what is covered
under Original Medicare.
As an Aetna Medicare Advantage contracted provider,
you are expected to understand what is covered under
Aetna Medicare Advantage plans. CMS mandates that
providers who are contracted with a Medicare Advantage
plan, such as Aetna, are not permitted to hold a Medicare
Advantage member financially responsible for payment
of a service not covered under the member’s Medicare
Advantage plan unless that member has received a
pre-service OD notice of denial from Aetna before such
services are rendered.
If the member does not have a pre-service OD notice of
denial from Aetna on file, you must hold the member
harmless for the noncovered services. You cannot charge
the member any amount beyond the normal cost-sharing
amounts (such as copayments, coinsurance and/or
deductibles).
However, if a service is never covered under Original
Medicare or is listed as a clear exclusion in the member’s
plan materials, you can hold the member financially liable
without a pre-service OD. However, you cannot hold a
member financially liable for services or supplies that are
only covered when medically necessary unless you go
through the OD process. Members cannot be expected
to know when a service is medically necessary and when
it is not.
Providers and members can initiate pre-service ODs.
You must go through this process to determine if the
requested or ordered service is covered prior to a
member receiving it, or prior to scheduling a service
such as a lab test, diagnostic test or procedure. The
procedure to request a pre-service OD is similar to the
procedure to request a prior authorization. Call the
number on the member’s ID card and ask for a
pre-service OD to determine if the service will be
covered for the member.
Once we make a determination, the member will be
notified of the decision. You will only be able to charge
the member for the service if the member has already
received the decision from us before you render the
services in question to the member.
51
Medicare prescription drug plan (PDP and MA-PD)
coverage determinations and exceptions process
Medicare beneficiaries enrolled in PDPs and MA-PDs
have the right to request a coverage determination
concerning the prescription drug coverage they’re
entitled to receive under their plan, including:
• Basic prescription drug coverage and supplemental
benefits
• The amount, including cost sharing, if any, that the
member is required to pay for a drug
An adverse coverage determination constitutes any
unfavorable decision made by or on behalf of Aetna
regarding coverage or payment for prescription drug
benefits a member believes they are entitled to receive.
The following actions are considered coverage
determinations:
• A decision not to provide or pay for a prescription
drug that the member believes should be covered by
the plan. (This includes a decision not to pay because
the drug is not on the plan’s formulary, is determined
to not be medically necessary, is furnished by an
out-of-network pharmacy, or we determine is otherwise
excluded under section 1862(a) of the Social Security
Act, if applied to Medicare Part D.)
• The failure to provide a coverage determination in a
timely manner when a delay would adversely affect
the health of the member.
• A decision concerning an exceptions request for a
plan’s tiered cost-sharing structure.
• A decision concerning an exceptions request involving
a nonformulary drug.
• A decision on the amount of cost sharing for a drug.
We have both standard and expedited procedures in
place for making coverage determinations.
Exceptions process
The exceptions process can be initiated for:
• Requests for exceptions involving a nonformulary
Part D drug
• Requests for exceptions to a plan’s tiered cost-sharing
structure
A decision by a Part D plan sponsor concerning an
exceptions request constitutes a coverage
determination. Therefore, all of the applicable coverage
determination requirements and time frames apply.
The member, their appointed representative or the
prescribing physician can submit an exceptions request
either orally or in writing, via phone or fax.
• Phone: 1-800-414-2386 (TTY: 711)
• Fax: 1-800-408-2386
Medicare coverage determinations and exception
requests have a strict turnaround time for completion.
It is critical that you send your requests to the correct
areas of Aetna Medicare so we may handle them
appropriately for our members. Send all Medicare
prescription drug requests via phone or fax.
• Phone: 1-800-414-2386 (TTY: 711)
• Fax: 1-800-408-2386
A complete description of our coverage determination
and exceptions process, and how to contact us if you are
assisting a member with this process, is available on our
Aetna Medicare Plans website:
Medicare Advantage (MA and MA-PD) and Medicare
PDP member grievance and appeal rights
Medicare beneficiaries enrolled in MA, MA-PD, or PDP
plans members are entitled to specific CMS-mandated
appeal and grievance rights. We have departments
dedicated to processing all member appeals and
grievances related to Medicare Advantage and Medicare
Part D coverage.
Appeals and grievances are processed in accordance
with the standard and expedited requirements and time
frames established by CMS. Following an adverse
organization determination or coverage determination,
MA or MA-PD plan and PDP members have the right to
appeal any decision about the plan’s failure to pay or
provide coverage for what the member believes are
covered benefits, drugs and services (including
non-Medicare covered benefits). MA members can
appeal for coverage of medical benefits, services and
drugs covered through the Medicare medical benefit.
PDP members can appeal for coverage of prescription
drugs. MA-PD members can appeal for any of the above.
We may ask for the cooperation and/or participation of
contracted providers in our internal and external review
of procedures relating to the processing of Medicare
member appeals and grievances. If necessary, contracted
providers should:
• Instruct the member to contact us for their MA plan
appeal rights
52
• Inform the member of their right to receive, upon
request, a detailed written notice from us regarding
coverage for services
• Promptly respond to any plan requests for information
needed to review an appeal or assist with grievance
resolution
Members should be directed to contact Member Services
using the phone number listed on their Aetna member
ID card. In addition, notices sent due to an adverse
organization or coverage determination provide contact
information and instructions for filing an appeal.
When a Medicare member appeals a denied service,
drug or other benefit they believe they are entitled to,
we may need clinical records from you. We require you
to handle all requests for clinical records as promptly
as possible.
There are instances when we have less than 48 hours to
respond to an appeal and your clinical information is
imperative to making an accurate and timely decision.
Please note that CMS-mandated time frames do not stop
due to weekends, holidays, or any other time when your
office may be closed.
For a complete description of our MA, MA-PD, and
Medicare PDP appeal and grievance procedures and
time frames, and how to contact Aetna if you are
assisting a member with this process, refer to the
following links:
• Aetna Medicare Rx Plan (PDP): Exceptions,
Appeals and Grievances (Part D requests for
MA-PD or PDP members)
• Aetna Medicare Advantage: Appeals and Grievances
(medical requests for MA or MA-PD members)
Obligation to respond to requests for records
We are required to ask our network providers to give us
clinical documentation to help make coverage decisions
for pharmacy or medical services. Under our contract
with you, you’re obligated to provide this information to
us promptly upon request. Our clinical staff will contact
your office by phone or fax when we need documentation.
The timelines for making coverage decisions are short and
highly regulated, so it is critical that you provide us with
the requested clinical information on a timely basis. If you
don’t, it adversely impacts your patients’ access to care
and results in unnecessary coverage denials. Please make
sure your staff knows they must respond quickly to
medical record requests. Failure to respond may impact
your future participation status.
Confidentiality and accuracy of member records
Contracted providers must safeguard the privacy and
confidentiality of, and ensure the accuracy of, any
information that identifies an MA plan member. Original
medical records must be released only in accordance
with federal or state laws, court orders or subpoenas.
Specifically, our contracted providers must:
• Maintain accurate medical records and other health
information
• Help ensure timely access by members to their medical
records and other health information
• Abide by all federal and state laws regarding
confidentiality and disclosure of mental health records,
medical records, other health information and member
information
• Provide staff with periodic training in member
information confidentiality
Refer to the “Privacy Practices” section on page 28 for
further information.
Coverage of renal dialysis services for Medicare
members who are temporarily out-of-area
An Aetna Medicare Advantage plan member may be
temporarily out of the service area for up to six months*
MAOs must pay for renal dialysis services obtained by an
MA plan member while the member is temporarily out
of their Medicare Advantage plan’s service area. These
services can be from a contracted or noncontracted
Medicare-certified physician or health care professional.
Direct access to in-network women’s health
specialists
Without a referral, MA plan members have direct access
to mammography screening services at a contracted
radiology facility. They also have direct access to
in-network women’s health specialists for routine and
preventive services.
Direct-access immunizations
Without a referral, MA members may receive influenza,
hepatitis B and pneumococcal vaccines from any network
provider. There is no cost to the member if any of these
vaccinations are the only service provided at that visit. A
PCP copayment will apply for all other immunizations that
are medically necessary, in addition to the cost of the drug.
53
Emergency services
Refer to the “ Your Rights” section of the Aetna website
for more information on emergency services.
Health-risk assessment
We offer all members the opportunity to complete a
health-risk assessment within 90 days of their enrollment
in an Aetna MA plan.
The information obtained through the assessment is
sent to the member’s primary care physician, if we have
one on file.
Receipt of federal funds, compliance with federal
laws and prohibition on discrimination
Payments received by contracted providers from MAOs
for services rendered to MA plan members include
federal funds. Therefore, a MAO’s contracted providers
are subject to all laws applicable to recipients of federal
funds. These include, without limitation:
• Title VI of the Civil Rights Act of 1964, as implemented
by regulations at 45CFR part 84
• The Age Discrimination Act of 1975, as implemented by
regulations at 45 CFR part 91
• The Rehabilitation Act of 1973
• The Americans with Disabilities Act
• Federal laws and regulations designed to prevent or
ameliorate fraud, waste and abuse, including, but not
limited to, applicable provisions of federal criminal law
• The False Claims Act (31 U.S.C. §§ 3729 et. seq.
• The anti-kickback statute (section 1128B(b) of the Social
Security Act)
• Health Insurance Portability and Accountability Act
(HIPAA) administrative simplification rules at 45 CFR
parts 160, 162 and 164
In addition, our contracted providers must comply with
all applicable Medicare laws, rules and regulations. And,
as provided in applicable laws, rules and regulations,
contracted providers are prohibited from discriminating
against any MA plan member on the basis of health status.
Provider terminations
When a provider’s participation in the Aetna Medicare
network is terminated, CMS requires that we make a
good-faith effort to provide written notice of the
termination. This notice must be at least 30 calendar
days prior to the termination effective date to all MA
plan members who are patients seen on a regular
basis by the provider.
However, note that when a PCP is terminated from the
Aetna Medicare network, all members who are patients
of that PCP must be notified of the PCP’s termination at
least 30 days prior to the termination effective date.
If you choose to terminate your Aetna Agreement with us,
on the other hand, your contract stipulates that you must
give us advance notice. For example, 90–120 days prior to
terminating (or based on your contractual language).
Aetna shall provide physicians a 60-day written notice before
terminating a physician contract without cause, unless a
greater timeframe is specified in the physician’s contract.
Financial liability for payment for services
In no event should an MAO’s contracted provider bill
an MA plan member (or a person acting on behalf of an
MA plan member) for payment of fees that are the legal
obligation of the MAO. However, a contracted provider
may collect deductibles, coinsurance or copayments
from MA plan members in accordance with the terms
of the member’s Evidence of Coverage.
Note: CMS issued a memo to MAOs dated September 17,
2008, (“CMS Guidance”) providing guidance regarding
balance billing by providers of certain individuals enrolled
in both Medicare Advantage plans and a State Medicaid
plan (“Dual Eligible beneficiaries”). More specifically, this
CMS Guidance states that providers are prohibited from
balance billing Dual-Eligible beneficiaries who are
classified as Qualified Medicare Beneficiaries (QMB) for
Medicare Parts A and B cost-sharing amounts.
The CMS Guidance explains that providers must accept
Medicare and Medicaid payment(s), if any, as payment in
full. A QMB has no legal liability to make payment to a
provider or MA plan for Medicare Part A or B cost sharing,
and a provider may not treat a QMB as a “private pay
patient” in order to bill a QMB patient directly. In addition,
the CMS Guidance states that federal regulations require a
provider treating an individual enrolled in a State Medicaid
plan, including QMBs, to accept Medicare assignment.
Providers participating in Aetna Medicare networks are
required to provide covered services to Aetna Medicare
Dual-Eligible beneficiaries enrolled in Aetna Medicare
Advantage plans (“Dual-Eligible members”) and comply
with all of the requirements set forth in this CMS
Guidance. Participating providers must accept Aetna
payment as payment in full or bill Medicaid for the Dual
Eligible member’s copayment.
54
Medicare Compliance Program requirements
CMS requires that Aetna first tier, downstream and
related entities (FDRs) fulfill Medicare Compliance
Program requirements. If you are contracted to provide
health care and/or administrative services for any of our
Medicare plans, you are an FDR.
Our Medicare plans include:
• Medicare Advantage (MA or MAPD)
• Medicare-Medicaid Plans (MMPs)
• Dual-Eligible Special Needs Plans (D-SNPs)
We describe all of CMS’ compliance program
requirements in our First Tier, Downstream and
Related Entities (FDR) Medicare Compliance
Program Guide (FDR Guide). Go to Aetna.com/
medicare to find the FDR Guide.
Be sure to review the FDR Guide and make sure you are
complying with all of the requirements.
Standards of Conduct and Compliance policies
Your organization should distribute Standards of
Conduct and Compliance Policies that explain your:
• Commitment to comply with federal and state laws
• Ethical behavior requirements
• Compliance program operations
Your policies should be distributed within 90 days of hire,
when revised, and annually thereafter.
If you don’t have your own documents, you can use our
Code of Conduct and Compliance Policies.
Exclusion list screening
Your organization should not employ or contract with an
individual or entity that is excluded from participating in
federally funded health care programs. Prior to contracting
and monthly thereafter, you must screen employees and
downstream entities against the following lists:
• Office of Inspector General (OIG) List of Excluded
Individuals and Entities
• General Services Administration (GSA) System for
Award Management (SAM)
If an excluded individual or entity is identified, you must
notify us and immediately remove them from working on
our Medicare business. This individual or entity should
not bill for Medicare-covered services, and Aetna cannot
pay such claims.
Patient Protection and Affordable Care Act (PPACA)
We refer to PPACA as the Affordable Care Act (ACA).
As part of the ACA, Congress enacted a broad new
law— ACA Section 1557 — that generally prohibits most
health insurers, including Aetna, from discriminating on
the basis of race, color, national origin, sex, disability or
age. A central element of the ACA Section 1557 rules is a
requirement that covered entities, including health care
providers such as hospitals or doctors, provide special
aids to persons with communication disabilities, such as
the deaf and hard of hearing, so they can equally access
and benefit from their services. Aetna expects providers
to comply with ACA Section 1557.
The “effective communication” baseline rule
As an Aetna Provider, you are obligated to do both of
the following:
• Ensure all communications with the deaf and hard of
hearing are as effective as those with other persons.
• Provide appropriate auxiliary supports and services to
the deaf and hard of hearing, whenever necessary, to
afford them an equal opportunity to benefit from their
services.
When deciding whether a particular aid should be
provided, keep in mind that the general goal is to ensure
all communications with individuals who are deaf or hard
of hearing are effective.
Individuals qualifying for auxiliary supports and
services
Individuals qualify for auxiliary supports and services
if either of the following apply:
• They are deaf or hard of hearing.
• They are in one of the classes of people covered
by the regulations.
The term “deaf” includes individuals who do not hear well
enough to rely on their hearing to process speech and
language. The term “hard-of-hearing” includes individuals
with conditions that affect the frequency or intensity of
their hearing. A deaf or hard-of-hearing person would
be covered by ACA Section 1557 if they are substantially
limited in hearing or substantially limited in some other
major life activity because of hearing loss. An individual
may be considered deaf or hard of hearing even if their
hearing loss is eased by the use of a hearing aid or
cochlear implant.
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Auxiliary support and service options
The regulations include a long, but nonexhaustive list of
auxiliary supports and services that may be provided in
a particular instance. The list includes (among other
possibilities):
• Qualified interpreters, who can provide services in
person and on-site or remotely through technology,
such as video remote interpreting (VRI)
• Use of written materials and exchange of written notes
• Voice-, text- and video-based telecommunications
products, such as video relay service (VRS)
• Text telephones, called “teletypewriters” (TTYs)
There are many other options, though all must be
provided free of charge to people who are deaf or hard
of hearing. Any special technology such as VRI or VRS
must meet technical and operational standards and
users must be properly trained. The appropriate aid to
use will depend on the individual with the disability, the
type of communication and the context. When deciding
which aid to provide, primary consideration should be
given to the person with a disability who is requesting
the service. Aids should also be provided in a timely
manner and in such a way that protects the privacy and
independence of the individual.
Persons qualified to act as interpreters
Interpreters used by covered entities (whether
interpreting in-person or via VRI) should be qualified.
A qualified interpreter may use one of several
methodologies, but must:
• Adhere to generally accepted interpreter ethics
principles, including client confidentiality
• Be able to interpret effectively, accurately, and
impartially, both receptively and expressively, using any
necessary specialized vocabulary, terminology and
phraseology
You must not require a person who is deaf or hard of
hearing to bring someone with him or her to interpret,
nor should you rely on an adult companion or child to
interpret, unless:
• There is an emergency involving an imminent threat to
the safety or welfare of the individual or the public and
no other interpreter is available
• The person requests interpretation from their
companion and reliance on the companion is
determined to be appropriate
For more from the Office of Civil Rights on effective
communications for persons who are hard of hearing, go
to the U.S. Department of Health and Human Services
website.
Oversight of your subcontractors
If your subcontractors provide health care and/or
administrative services for the Aetna Medicare business,
they are a downstream entity.
You must ensure that your downstream entities abide by
all laws, rules and regulations. This includes ensuring your:
• Contractual Agreements contain all CMS-required
provisions
• Downstream Entities comply with applicable Medicare
requirements, including operational and compliance
program requirements
What may happen if you don’t comply
If our FDRs fail to meet these CMS Medicare compliance
program requirements, it may lead to:
• Development of a corrective action plan
• Retraining
• Termination of your contract and relationship with Aetna
Making sure you maintain documentation
You are required to maintain evidence of your compliance
with the requirements for 10 years. Aetna or CMS may
request that you provide documentation of your compliance
with these requirements.
Annual attestation
Each year, on behalf of your organization, an authorized
representative is required to review the FDR Guide and
go to Aetna.com/medicare to complete the Aetna
Medicare Compliance Attestation. In addition to
completing an attestation, we and/or CMS may request
that you provide evidence of your compliance with these
Medicare Compliance Program requirements.
Report concerns or questions
If you identify noncompliance or fraud, waste and abuse,
you can report it to us by using the mechanisms outlined
in our Code of Conduct. We prohibit retaliation for
good-faith reporting of concerns.
If you have questions about the requirements that apply
to FDRs or if you have difficulty finding our FDR Guide,
contact the Provider Contact Center.
Medicare Access and CHIP Reauthorization Act
(MACRA) reimbursement policy
The Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) was signed into law on April 16, 2015. MACRA
created the Quality Payment Program (QPP), which repeals
the Sustainable Growth Rate (SGR) formula. It changes the
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way Medicare rewards physicians for value versus volume
over time.
Our MACRA reimbursement policy applies to both of the
payment tracks below:
• Advanced Alternative Payment Model (AAPM): our
value-based contracting reimbursement programs are
known as “CPC+” or “Medicare Collaboration Premier”
or “Medicare Collaboration Enhanced.” They offer
providers CMS-approved options to qualify for this
track as an Other Payer AAPM as long as the AAPM
criteria are met within your specific contract terms.
However, our provider reimbursements do not adjust
to include reciprocal AAPM bonuses. AAPM bonuses
are based on CMS Fee-For-Service membership, not
your Aetna-specific membership.
• Merit-Based Incentive Payment System (MIPS):
our provider reimbursements do not adjust to include
performance-based incentive payments made under
traditional Medicare as the result
of MACRA. Incentive payments are based on
CMS Fee-For-Service membership, not your
Aetna-specific membership.
Temporary move out of the service area
CMS defines a temporary move as:
• An absence from the service area (where the member
is enrolled in an MA plan) of six months* or less
• Maintaining a permanent address/residence in the
service area
An MA plan member is covered while temporarily out of
the service area for emergent, urgent and out-of-area
dialysis services. If a member permanently moves out of
the MA plan service area or is absent for more than six
months,* the MAO must disenroll the member from the
MA plan.
Travel programs — when members are away from
home for an extended period
Under travel programs, we let members travel out of
their home service area for an additional 6 months for a
total of 12 months in a row. Members travelling can get
services from providers in our Medicare network for the
service area they’re visiting. Plan coverage rules still
apply. For example, they may need referrals for some
services. Our Medicare network isn’t in all locations, so it
is important members check for participating providers
in the area they’re visiting.
We offer two Medicare Advantage visitor/traveler
programs
• Travel Advantage (HMO plans)
• Travel Explorer (PPO plans)
1. Travel Advantage (HMO plans)
Travel Advantage is offered on some Individual and
Group Medicare Advantage HMOs. It’s not available to
California (CA) or Florida (FL) members or to those
members enrolled in our Medicare Advantage Prime
Plan.
• Visitor Traveler: allows members to keep their plan
coverage for an extra six months when out of the plan’s
service area.
• Seamless network: multi-state network allows HMO
members to get routine services at an in-network cost
share when they see a contracted Aetna HMO provider
throughout the United States. An HMO member cannot
see a PPO-contracted provider.
• Medicare Advantage Open Access HMO: members
don’t choose PCPs. When enrolled in Travel Advantage,
members can continue using any Aetna Medicare
Advantage HMO provider without a referral.
• Medicare Advantage non-Open Access HMO:
members whose plans need referrals and PCP choices
have to change their PCP to another PCP in the service
area they’re visiting. The new PCP renders primary care
services and refers members to other providers in the
service area they’re visiting.
2. Travel Explorer (PPO plans)
Travel Explorer is offered on some Individual
Medicare Advantage PPO plans and includes “Travel
Pass.” For 2020, the Explorer travel program is
available on some Individual Medicare Advantage PPO
plans in the states listed below:
Alabama (AL)
Arizona (AZ)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
Florida (FL)
Georgia (GA)
Illinois (IL)
Indiana (IN)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Massachusetts (MA)
Michigan (MI)
Mississippi (MS)
Nevada (NV)
New Jersey (NJ)
New York (NY)
North Carolina (NC)
Ohio (OH)
Pennsylvania (PA)
South Carolina (SC)
Tennessee (TN)
Utah (UT)
Virginia (VA)
Washington (WA)
Wisconsin (WI)
Wyoming (WY)
*Twelve months for members enrolled in a stand-alone Medicare prescription drug plan (PDP).
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• Visitor Traveler: allows members to stay in their
plans for an extra six months when out of the plan’s
service area.
• Seamless network: multi-state network allows PPO
members to get routine services at an in-network cost
share when they see a contracted Aetna PPO-provider
throughout the United States.
• Travel Pass: gives a snapshot of key health care
elements such as their primary care provider, medication
history, vaccine history and other information — all of
which can help members direct their care while traveling.
Plans rules and requirements must be followed
• Members may only change to PCP in another Medicare
Aetna plan service area.
• If a plan requires a PCP, members must change their
PCP. If they don’t, their claims will be denied.
• Members must get PCP referrals in accordance with
plan rules.
Urgently needed services
Urgently needed services are covered services provided
to a member that are both of the following:
• Nonpreventive or nonroutine
• Needed to prevent the serious deterioration of a
member’s health following an unforeseen illness, injury
or condition
Urgently needed services include conditions that cannot
be adequately managed without immediate care or
treatment, but do not require the level of care provided
in the emergency room.
Physicians and other health care professionals and
marketing of Aetna Medicare Advantage plans
MAOs and their contracted providers must adhere to all
applicable Medicare laws, rules and regulations relating
to marketing. Per Medicare regulations, “marketing
materials” include, but are not limited to, promoting an
MAO or a particular MA plan, informing Medicare
beneficiaries that they may enroll or remain enrolled in
an MA plan offered by an MAO, explaining the benefits of
enrollment in an MA plan or rules that apply to members,
or explaining how Medicare services are covered under
an MAO plan.
Regulations prevent MAOs from conducting sales activities
in health care settings except in common areas. MAOs
are prohibited from conducting sales presentations and
distributing and/or accepting enrollment applications in
areas where patients primarily intend to receive health
care services. MAOs are permitted to schedule
appointments with beneficiaries residing in long-term
care facilities, only if the beneficiary requests it.
Physicians and other health care professionals may discuss,
in response to an individual patient’s inquiry, the various
benefits of MA plans. They shall remain neutral when
assisting Medicare beneficiaries with enrollment decisions.
Physicians are encouraged to display plan materials for all
plans in which they participate.
For additional information, physicians and health care
professionals can also refer their patients to:
• 1-800-624-0756 (TTY: 711)
• The State Health Insurance Assistance program
• The specific MAO marketing representatives
• The CMS website at Medicare.gov
Physicians and other health care professionals cannot
accept MA plan enrollment forms.
We follow the federal anti-kickback statute and CMS
marketing requirements associated with Medicare
marketing activities conducted by providers and related
to Aetna Medicare plans. Payments that we make to
providers for covered items and/or services will:
• Be fair market value
• Be consistent with an arm’s length transaction
• Be for bona fide (genuine) and necessary services
• Comply with relevant laws and requirements, including
the federal anti-kickback statute
For a complete description of laws, rules, regulations,
guidelines and other requirements applicable to
Medicare marketing activities conducted by providers,
refer to Chapter 3 of the Medicare Managed Care
Manual, and the Medicare Communications and
Marketing Guidelines contained therein, which can
be found on the CMS website.
Annual notice of change
Medicare plan benefits are subject to change annually.
Members are provided with written notice regarding the
annual changes by the date specified by CMS. The CMS
Annual Election Period typically runs from October 15
through December 7 for the upcoming calendar year for
beneficiaries enrolled in individual MA-only, MA-PD, and
PDP plans. Elections made during the Annual Election
Period are effective January 1 of each year. Providers can
access the Aetna Medicare website for information on
the individual plans and benefits that will be available
within their service area for the following calendar year.
58
Services received under private contract
As specified by Medicare laws, rules and regulations,
physicians may “opt out” of participating in the Medicare
program and enter into private contracts with Medicare
beneficiaries. If a physician chooses to opt out of
Medicare due to private contracting, no payment can
be made to that physician directly or on a capitated
basis for Medicare-covered services. The physician
cannot choose to opt out of Medicare for some Medicare
beneficiaries but not others, or for some services but
not others.
The MAO is not allowed to make payment for services
rendered to MA members to any physician or health care
professional who has opted out of Medicare due to private
contracting, unless the beneficiary was provided with
urgent or emergent care.
Claims and billing requirements
Physicians and other health care professionals must use
the current revision of the International Classification of
Diseases, Clinical Modification (ICD-10-CM) codes and
adhere to all conventions and guidelines specified in the
ICD-10-CM Official Guidelines for Coding and Reporting.
Complete, accurately use both the CMS Healthcare
Common Procedure Coding System (HCPCS Level II) and
the required procedural codes of the American Medical
Association’s (AMA’s) Current Procedural Terminology
(CPT), current edition.
Hospitals and physicians using the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition,
(DSMV) for coding must convert the information to
the official ICD-10 CM codes. Failure to use the proper
codes will result in diagnoses being rejected in the
Risk-Adjustment Processing System.
• The ICD-10 CM codes must be to the highest level of
specificity: A code is invalid if it does not contain the full
number of required characters detailed in the tabular
list. Valid codes may contain three to seven characters.
• Report all secondary diagnoses that impact clinical
evaluation, management and/or treatment.
• Report all status codes pertinent to the care provided.
An unspecified code should not be used if the medical
record provides adequate documentation for
assignment of a more specific code.
Again, failure to use current coding guidelines may result
in a delay in payment and/or rejection of a claim.
Submitting Medicare claims and encounter data
for risk adjustment
Risk adjustment is used to fairly and accurately adjust
payments made to MAOs by CMS based on the health
status and demographic characteristics of an enrollee.
CMS requires MAOs to submit diagnosis data regarding
physician, inpatient and outpatient hospital encounters
on a quarterly basis, at minimum.
CMS uses the Hierarchical Condition Category payment
model referred to as CMS-HCC model. This model uses the
ICD-10 CM as the official diagnosis code set in determining
the risk-adjustment factors for each member. The risk
factors based on HCCs are additive and are based on
predicted expenditures for each disease category. For
risk-adjustment purposes, CMS classifies the ICD-10 CM
codes by disease groups known as HCCs.
Providers are required to submit accurate, complete and
truthful risk-adjustment data to the MAO. Failure to submit
complete and accurate risk-adjustment data to CMS may
affect payments made to the MAO and payments made
by the MAO to the physician or health care professional
organizations delegated for claims processing.
Risk adjustment medical record validation
CMS conducts medical record reviews to validate the
accuracy of the risk-adjustment data submitted by
the MAO. Medical records created and maintained by
providers must correspond to and support the hospital
inpatient, outpatient and physician diagnoses submitted
by the provider to the MAO. In addition, Medicare
Advantage regulations require that providers submit
samples of medical records for validation of
risk-adjustment data and the diagnoses reported by
Aetna to CMS, as required by CMS.
Therefore, providers must give access to and maintain
medical records in accordance with Medicare laws,
rules and regulations. (Refer to the “Access to Facilities
and Records” section on page 49.) CMS may adjust
payments to the MAO based on the outcome of the
medical record review.
Providers of hospice-related services
Aetna Medicare Advantage members may elect to use the
hospice benefit in the Original Medicare program instead
of their MA HMO and PPO coverage. Prior to initiating
hospice care, the member or their representative must
sign the “Election of Benefits” waiver. When this election
is documented, the enrollee should be referred to the
Original Medicare hospice provider.
59
Original Medicare will assume financial responsibility on
the date the waiver is signed, and reimbursement will be
made by Original Medicare directly to the agency. Durable
medical equipment (DME) will be the responsibility of the
hospice provider. The MA plan remains responsible for
payment of those medical services not related to the
terminal illness and additional benefits not covered by
Medicare. An example of an additional benefit is the
eyeglasses reimbursement.
For services not related to the terminal illness, inpatient
services should be billed to the Medicare Fiscal
Intermediary using the condition code “07.” For physician
services and ancillary services not related to the terminal
illness, the physician or other health care professional
should bill the Medicare carrier (as is done for Medicare
FFS patients) and use the modifier “GW.”
Attending physician services are billed to the Medicare
carrier with the “GV” modifier, provided these services
were not furnished under a payment arrangement with
the hospice. If another physician covers for the
designated attending physician, the services of the
substituting physician are billed by the designated
attending physician under the reciprocal or locum
tenens billing instructions. In such instances, the
attending physician bills using the “GV” modifier in
conjunction with either a “Q5” or “Q6” modifier.
Centers for Medicare & Medicaid Services (CMS)
physician incentive plan: general requirements
Aetna Medicare Advantage regulations require that
MAOs and their participating providers meet certain
CMS monitoring and disclosure requirements that apply
to “physician incentive plans.” As outlined in 42 C.F.R §
422.208(a), a “physician incentive plan” means any
compensation arrangement to pay a physician or
physician group that may directly or indirectly have
the effect of reducing or limiting the services provided
to any MA plan enrollee.
The physician incentive plan requirements apply to an
MAO and any of its first-tier and downstream provider
arrangements that utilize a physician incentive plan in
their payment arrangements with individual physicians
or physician groups. Provider downstream arrangements
may include an intermediate first-tier entity. This includes,
but is not limited to, an independent practice association
(IPA) that contracts with one or more physician groups or
any other organized group that provides administrative
and/or health care services to MA members through
downstream providers.
CMS imposes the following requirements on MAOs and
their participating providers regarding physician
incentive plan arrangements:
• MAOs and their participating providers cannot make
a specific payment, directly or indirectly, to a physician
or physician group as an inducement to reduce or limit
medically necessary services furnished to any particular
MA enrollee. Indirect payments may include offerings
of monetary value (such as stock options or waivers
of debt) measured in the present or future.
• If the physician incentive plan places a physician or
physician group at substantial financial risk for services
that the physician or physician group does not furnish
itself, the MAO or participating provider must ensure
that all physicians and physician groups at substantial
financial risk (as described in 42 C.F.R §422.208(a) & (d))
have either aggregate or per-patient stop-loss protection
(as described in 42 C.F.R §422.208(f)). In addition, MAOs
and participating providers must conduct periodic Aetna
MA member surveys in accordance with MA regulations.
• For all physician incentive plans, the MAO must provide
CMS with assurances that applicable physician incentive
plan requirements are met, as well as provide information
concerning physician incentive plans, as requested. To
meet this CMS requirement, any participating provider
with a physician incentive plan arrangement must annually
provide Aetna with the following information for each
physician incentive plan arrangement:
- Whether referral services are covered by the physician
incentive plan
- The type of physician incentive plan arrangement
(that is, withhold, bonus, capitation)
- The percent of total income at risk for referrals
- The patient panel size
- The amount and type of stop-loss protection
We will disclose any physician incentive plan arrangements
maintained by participating providers, if required to do so,
under applicable laws and regulations.
CMS physician incentive plan: substantial
financial risk
As more fully described in 42 C.F.R. § 422.208 (a) and (d),
substantial financial risk occurs when risk is based on the
use or costs of referral services and that risk exceeds a risk
threshold of 25% of potential payments. (Payments based
on other factors, such as quality of care furnished, are not
considered in this determination.) Refer to 42 C.F.R. §
422.208 for additional information.
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CMS physician incentive plan: stop-loss protection
requirements
In addition, as more fully described in 42 C.F.R. §422.208(f),
MAOs and their participating providers must ensure that
all physicians and physician groups at substantial financial
risk have either aggregate or per-patient stop-loss
protection in accordance with the following requirements:
• Aggregate stop-loss protection must cover 90% of
the costs of referral services that exceed 25% of
potential payments.
• For per-patient stop-loss protection, if the stop-loss
protection provided is on a per-patient basis, the
stop-loss limit (deductible) per patient must be
determined based on the size of the patient panel.
It may be a combined policy or consist of separate
policies for professional services and institutional
services. In determining patient panel size, the patients
may be pooled, as described in 42 C.F.R. § 422.208(g).
• Stop-loss protection must cover 90% of the costs of
referral services that exceed the per-patient deductible
limit. The per-patient stop-loss deductible limits are set
forth in 42 C.F.R. § 422.208(f).
Participating providers with physician incentive plan
arrangements must maintain, at their sole expense,
any stop-loss coverage they are required to maintain
under applicable laws and regulations. They must also
provide evidence of such coverage to us upon request.
Aetna Medicare Advantage organization (MAO)
obligations
The MAO is prohibited from restricting a physician or health
care professional from advising his or her patients about:
• Their health status
• Their treatment options
• The risks and benefits of their treatment options
• The opportunity to refuse treatment and/or express
preferences about future treatment decisions
CMS: CY 2019 Medicare Communications and
Marketing Guidelines (MCMG)
In 2018, CMS released new guidelines: CY 2019 Medicare
Communications and Marketing Guidelines (MCMG).
Review Section 60 — Activities in a Healthcare Setting
for complete details.
Provider-initiated activities are those conducted by a
health care professional at the request of the patient or
as a matter of a course of treatment, when meeting with
the patient as part of the professional relationship.
Permissible activities
• Distributing unaltered, printed materials created by CMS
• Providing the names of plans with which they participate
• Answering questions or discussing the merits of a plan
or plans, including cost sharing and benefits
information (these discussions may occur in areas
where care is delivered)
• Referring patients to other sources of information, such
as State Health Insurance Assistance Program (SHIP),
plan marketing representatives, their state Medicaid or
Social Security office, or Medicare via Medicare.gov or
1-800-Medicare (1-800-633-42273)
• Referring patients to plan marketing materials available
in common areas
• Providing information and help applying for the
low-income subsidy (LIS)
What contracted providers may do
• Make communication materials available, including
in areas where care is delivered
• Make plan marketing materials and enrollment forms
available outside of the areas where care is delivered
(such as common entryways or conference rooms)
Distributing or making plan marketing materials available
is allowed as long as the provider does this for all plans
in which they participate. Providers must remain
neutral when helping beneficiaries with
enrollment decisions.
Ambulance services
Ambulance services, including fixed-wing and
rotary-wing ambulance services, are covered only if they
are furnished to a member whose medical condition is
such that other means of transportation are contraindicated.
The member’s condition must require both the ambulance
transportation itself and the level of service provided in
order for the billed service to be considered medically
necessary. Note that air ambulance services are covered
only if the member’s medical condition is such that
transportation by ground ambulance is not appropriate.
The member must be transported to the nearest hospital
with appropriate facilities.
Nonemergency, scheduled, and repetitive ambulance
services may be covered if the ambulance provider or
supplier, before furnishing the service to the beneficiary,
obtains a physician certification statement dated no earlier
than 60 days before the date the service is furnished
indicating that these services are medically necessary.
*Twelve months for members enrolled in a stand-alone Medicare prescription drug plan (PDP).
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Rights and responsibilities for Aetna Medicare
Advantage HMO and PPO plan members with a
prescription drug benefit
We inform our Aetna Medicare Advantage HMO and PPO
plan members with a prescription drug benefit included
in the plan design that they have the following rights and
responsibilities.
Information
• Get information about our plan. This includes
information about how we’re doing financially, and how
our plan compares to other Medicare health plans.
• Get information about our network providers, including
our network pharmacies.
• Have questions from non-English-speaking
beneficiaries answered. We make individuals and
translation services available. And the information we
provide about our benefits must be accessible and
appropriate for people who are eligible for Medicare
because of disability.
• Get an explanation about any prescription drugs and
Part C medical care or service not covered by our plan.
• Receive in writing: Why we will not pay for or approve a
prescription drug or Part C medical care or service
• How they can file an appeal to ask us to change this
decision even if they obtain the prescription drug or
Part C medical care or service from a pharmacy or
provider not in the Aetna network
• Receive an explanation about any utilization
management requirements, such as step therapy or
prior authorization, which may apply to their plan.
• Make a complaint if they have concerns or problems
related to their coverage.
• Be treated fairly (that is, not retaliated against) if they
make a complaint.
• Get a summary of information about the appeals made
by members and the plan’s performance ratings,
including how it’s been rated by plan members and how
it compares to other Medicare health plans.
• Get more information about their rights, and
protections, plus ask questions and share concerns.
- Call Aetna Member Services.
• Get free help and information from their State Health
Insurance Assistance Program (SHIP).
- Visit Medicare.gov to view or download the publication.
It’s available at Medicare.gov/Publications.
- Call 1-800-Medicare (1-800-633-4227) 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.
- Call the Office for Civil Rights at 1-800-368-1019 if they
think we’ve treated them unfairly or not respected their
rights. TTY users should call 1-800 -537-7697.
Access to care
• Choose a network health care provider. If they’re a
member of a Medicare PPO plan or PPO plan with an
Extended Service Area, they have the right to seek care
from any health care provider in the United States who
is eligible to be paid by Medicare and agrees to accept
the plan. They may pay more for services obtained from
an out-of-network provider.
• Go to a women’s health specialist in our plan
(such as a gynecologist) without a referral.
• Get timely access to providers. “Timely access” means
getting services within a reasonable amount of time.
• Get their prescriptions filled within a reasonable
amount of time at any network pharmacy.
Freedom to make decisions
• Get full information from their health care providers
when they go for medical care. This includes knowing
about all of the treatment options that are
recommended for their condition, no matter the cost or
whether they’re covered by our plan.
• Participate fully in decisions about their health care.
Their health care providers must explain things in a way
that they can understand. Their rights include knowing
about all of the treatment options that are
recommended for their condition, no matter the cost
or whether they’re covered by our plan.
• Know about the different medication therapy
management programs they may join.
• Be told about any risks involved in their care.
• Be told beforehand if any planned medical care or
treatment is part of a research experiment. They must
be given the choice to refuse experimental treatments.
• Refuse treatment. This includes the right to leave a
hospital or other medical facility, even if their doctor
advises them not to leave. This includes the right to
stop taking their medication.
• Receive a detailed explanation if they think a health
care provider has denied care they believe they were
entitled to receive or should continue to receive.
62
In these cases, they must request an initial decision,
called an “organization determination.”
• Ask someone such as a family member or friend to help
them with decisions about their health care. They may
fill out a form to give someone the legal authority to
make medical decisions for them.
• Give their doctors written instructions about how they
want them to handle their medical care. This includes
“Advanced Directives,” a “Living Will,” and a “Power of
Attorney for Health Care,” if they become unable to
make decisions for themself. They can contact Aetna
Member Services to ask for the forms.
Personal rights
• Be treated with dignity, respect and fairness at all times.
We must obey laws that protect them from
discrimination or unfair treatment. We do not
discriminate based on a person’s race, mental or
physical disability, religion, gender, sexual orientation,
health status, ethnicity, creed, age, claims experience,
medical history, genetic information, evidence of
insurability, geographic location within the service area
or national origin. Receive privacy of their medical
records and personal health information according to
federal and state laws that protect the privacy of their
medical records and personal health information. There
are exceptions allowed or required by law, such as the
release of health information to government agencies
that are checking on quality of care.
• Receive a written notice called a “Notice of Privacy
Practice” that tells them about privacy of their medical
records and personal health information rights and
explains how we protect the privacy of their health
information.
• Look at medical records held at the plan, and get a copy
of their records.
• Ask us to make additions or corrections to their
medical records.
• Know how we’ve given out their health information
and used it for nonroutine purposes.
Get information from us about our network pharmacies,
providers and their qualifications, as well as information
about how we pay our doctors. For a list of the providers
and pharmacies in the plan’s network, they may see
the Provider Directory. For more detailed information
about our providers or pharmacies, they may visit
AetnaMedicare.com or call Aetna Member Services.
Input
• Suggest changes in the plan’s policies and
services, including our Member Rights and
Responsibilities policy.
As a member in a Medicare Advantage HMO and PPO
plan with a prescription drug benefit included in the
plan design, they have a responsibility to:
• Exercise their rights
• Learn about their coverage and the rules they must
follow to get care as a member.
Follow instructions
• Unless it’s an emergency, when seeking care, they
must let health care providers know that they’re
enrolled in our plan. They must also present their
member ID card to health care providers.
• Give their doctor and other health care providers the
information they need to care for them.
• Follow the treatment plans and instructions that they
and their doctors agree on.
• Act in a way that supports the care given to other
patients and helps the smooth running of their doctor’s
office, hospitals and other offices.
• Tell our plan if they have additional health insurance or
drug coverage and use all of their insurance coverage.
• Pay their plan premiums and copayments/coinsurance
for their covered services.
• Pay for services that aren’t covered.
Communicate
• Ask their doctors and other providers if they have any
questions, and have providers explain their treatment
in a way that they can understand.
• Tell their doctor or other health care providers that
they’re enrolled in our plan. Show their member ID
card whenever they get their medical care or Part D
prescription drugs.
• Let us know if they move.
• Let us know if they have any questions, concerns,
problems or suggestions.
Rights and responsibilities for Aetna Medicare
Advantage HMO and PPO plan members
without a prescription drug benefit
We inform our Aetna Medicare Advantage HMO and PPO
plan members without a prescription drug benefit that
they have the following rights and responsibilities.
63
Information
• Get information about our plan. This includes
information about our financial condition and how our
plan compares to other Medicare health plans.
• Get information about our network providers.
• Get information in a way that works for them.
Our plan has people and free language interpreter
services available to answer questions from
non-English-speaking members. We can also give
members information in Braille, in large print or other
alternate formats if they need it.
• Get an explanation about any Part C medical care or
service not covered by our plan. Receive a written note
explaining why we will not pay for, or approve, a Part C
medical care or service
• File an appeal to ask us to change this decision, even
if they obtain the Part C medical care or service from
a provider not affiliated with our organization
• Make a complaint if they have concerns or problems
related to their coverage.
• Be treated fairly (that is, not be retaliated against) if
they make a complaint.
• Get information about the appeals made by members
and the plan’s performance ratings, including how it
compares to other Medicare health plans.
• Get more information about their rights. If they have
questions or concerns about their rights and
protections, they can call Aetna Member Services
• Get free help and information from their State Health
Insurance Assistance Program (SHIP)
• Visit Medicare.gov to view or download the publication.
Find it at Medicare.gov/publications?pubs/pdf/10112.pdf.
• Call 1-800-Medicare (1-800-633-4227) 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048.
• Call the Office for Civil Rights at 1-800-368-1019 if they
think we’ve treated them unfairly or not respected their
rights. TTY users should call 1-800-537-7697.
Access to care
• Choose a network health care provider. If they’re a
member of a private fee-for-service plan, they have the
right to seek care from any health care provider in the
United States who is eligible to be paid by Medicare and
agrees to accept our terms and conditions of payment.
• Get timely access to providers. “Timely access” means
getting services within a reasonable amount of time.
• Go to a women’s health specialist in our plan (such as a
gynecologist) without a referral.
• Call member services if they have a disability and need
help with access to care
Freedom to make decisions
• Get full information from their providers when they go
for medical care.
• Participate fully in decisions about their health care.
Their providers must explain things in a way that they
can understand. Their rights include knowing about all
of the treatment options that are recommended for
their condition, no matter the cost or whether they’re
covered by our plan.
• Be told about any risks involved in their care.
• Be told beforehand if any planned medical care or
treatment is part of a research experiment. They must
be given the choice of refusing experimental treatments.
• Refuse treatment. This includes the right to leave a
hospital or other medical facility, even if their doctor
advises them not to leave. This includes the right to
stop taking their medication.
• Receive a detailed explanation if their provider denied
care that they believe they were entitled to receive.
Or care they believe they should continue to receive.
In these cases, they must request an initial decision
called an “organization determination.”
• Ask someone such as a family member or friend to help
them with decisions about their health care. They may
fill out a form to give someone the legal authority to
make medical decisions for them.
• Give their doctors written instructions about how they
want them to handle their medical care. This includes
“Advanced Directives,” “Living Will” and “Power of
Attorney for Health Care” if they become unable to
make decisions for themself. They can contact member
services to ask for the forms.
Personal rights
• Be treated with dignity, respect and fairness at all times.
We must obey laws that protect members from
discrimination or unfair treatment. We do not
discriminate based on a person’s:
- Race
- Mental or physical
disability
- Religion
- Gender
- Sexual orientation
- Health status
- Ethnicity
- Creed
- Age
- Claims experience
- Medical history
- Genetic information
- Evidence of insurability
- Geographic location
within the service area
- National origin
64
• Have the privacy of their medical records and personal
health information protected as required by federal and
state laws. There are exceptions allowed or required by
law, such as release of health information to government
agencies that are checking on quality of care.
• Receive a written notice called a “Notice of Privacy
Practice” that tells them about privacy of their medical
records and personal health information rights and
explains how we protect the privacy of their health
information.
• Look at medical records held at the plan, and get a
copy of their records.
• Ask Aetna to make additions or corrections to their
medical records.
• Know how their health information has been given
out and used for non-routine purposes.
• See the Provider Directory for a list of the providers
in the plan’s network. Call Member Services or visit
AetnaMedicare.com to learn more about our providers.
Input
• Suggest changes in the plan’s policies and services,
including our Member Rights and Responsibilities policy.
As an Aetna Medicare Advantage HMO and PPO plan
member without a prescription drug benefit, they
have a responsibility to:
• Exercise their rights.
• Learn about their coverage and the rules they must
follow to get care as a member.
Follow instructions
• Tell their doctor or other health care providers that
they’re enrolled in our plan. Show their member ID card
whenever they get medical care.
• Give their doctor and other health care providers the
information they need to care for them.
• Follow the treatment plans and instructions that they
and their doctors agree upon.
• Act in a way that supports the care given to other
patients and helps the smooth running of their doctor’s
office, hospitals and other offices.
• Tell our plan if they have additional health insurance
and use all of their insurance coverage.
• Pay their plan premiums, copayments and coinsurance
for their covered services.
• Pay for services that aren’t covered.
Communicate
• Ask their doctor and other health care providers, if
necessary, for simple explanations of their treatment..
• Let us know if they move.
• Let us know if they have any questions, concerns,
problems or suggestions.
Physician–member communications policy
Our contracts with participating providers do not contain
“gag clauses.” Nothing about the contract prevents the
physicians or other health care professionals from
discussing issues openly with their patients. We include
language in our contracts to promote open physician–
member communication. The objective is to give our
members the comfort of knowing their physicians and
other health care professionals have the right and the
obligation to speak freely with them.
We encourage providers to discuss with their patients:
• Pertinent details regarding the diagnosis of
their conditions
• The nature and purpose of any recommended
procedure
• The potential risks and benefits of any
recommended treatment
• Any reasonable alternatives to such recommended
treatment
65
Coventry workers’ compensation
and Coventry Auto Solutions
About Coventry
Coventry offers workers’ compensation, auto and
disability care and cost management solutions for
employers, insurance carriers and third-party
administrators. With roots in both clinical and network
services, we leverage 30+ years of industry experience,
knowledge and data analytics. As part of the specialty
division of Aetna, our mission is returning people to
work, to play and to life.
Workers’ compensation
As a provider in the Coventry workers’ compensation
network, known as the Coventry Integrated Network
SM
,
you participate in the largest national network in the
workers’ compensation industry. Coventry Workers’ Comp
Services actively markets your practice to insurance
carriers, resellers, managed care organizations, third-party
administrators and employers within your area.
Additionally, Coventry Workers’ Comp Services provides
Managed Care Organization (MCO) services in a number
of states where MCO programs are supported by statute.
Our MCOs are designed to manage medical costs and
return-to-work outcomes without compromising quality
of care. In addition, Coventry monitors legislative and
regulatory changes in these states in order to ensure
continued compliance and to identify opportunities to
improve outcomes.
To help support the network, Coventry Workers’ Comp
Services offers workers’ compensation payers and
employers access to online directories and worksite
posters. Go to CoventryWCS.com and use the
directories and posters to help direct injured workers to
identify participating network providers.
Contact information and links
Coventry Workers’ Comp services:
• Phone: 1-800-937-6824 (TTY: 711)
• Website: CoventryAutoSolutions.com
Payer contact information:
• Website: CoventryProvider.com
Workers’ compensation tool
You can use CoventryProvider.com to easily complete
some of your daily tasks, including these related to
workers’ compensation:
• View bills, explanation of review (EOR) or pricing sheets
• Visit the Jopari portal
• Refer a patient to a workers’ compensation provider
• Locate provider resources specific to workers’
compensation products
Just log in to CoventryProvider.com, our provider website.
Injured worker and client identification
Coventry is dedicated to providing information important
to our network doctors and hospitals. To this end, Coventry
Workers’ Comp Services makes available a detailed list
with payer contact information. The list includes Coventry
Workers’ Comp Services clients and payers who access
the Coventry Network for workers’ compensation:
To find the list, go to CoventryAutoSolutions.com,
the worker’s compensation website, and look under the
provider tool section. Or go to CoventryProvider.com
to access it directly.
Referral process
As a Participating Provider in Coventry Integrated Network,
you should attempt to refer injured workers to other
participating providers. Use of our network providers helps
injured workers maximize their medical benefits and
reduce their related out-of-pocket expense.
To determine who to refer to in network, go to
CoventryProvider.com and visit the “Refer a Patient”
section. Or call 1-800-937-6824 (TTY: 711).
With this tool, you can quickly:
• Search for a provider by name
• Search by address
• Search by region
• View the Directory Library for pregenerated statewide
and regional directories
66
Claims administration information
• Verification of compensability
Verify the injured worker’s compensability status by
calling the injured worker’s payer or clams administrator.
• Utilization management and precertification
Utilization management requirements for workers’
compensation patients vary from state to state. Contact
the payer or claims administrator to verify utilization
management or precertification requirements.
• Billing, payment and claims
Provider/clinic claims for patients are typically billed
electronically or on the CMS-1500 and UB-04 (or
successor) forms and submitted by the provider’s
office. Incomplete forms or claims sent to the incorrect
address may cause delays in payment.
• Contracted amounts and allowable PPO
In accordance with state workers’ compensation laws,
the injured worker should not be balance-billed for the
difference between the contracted amount and the
total billed charges.
• Guarantees of payment, prepayment agreements
and separate fee arrangements
Providers should not enter into separate
contracted-amount agreements with Coventry clients.
• Covered services not medically necessary
Injured workers will not be billed for services that are
determined to be ‘‘not medically necessary.’’
• Billing follow up
Initial billing follow-up calls should be made to the
payer or its administrator.
• Explanation of review (EOR)
- Varies from payer to payer
- For Workers’ Comp questions related to an EOR, call
the Customer Service telephone number located on
the specific EOR
Provider responsibilities
Your responsibilities depend largely on the state in which
you operate. Go to CoventryWCS.com to find
information about state-specific requirements.
Under this section you’ll be able to access information
required by specific states by using the state drop-down
box located on the right-hand side of the page.
Participants in the Coventry Integrated
Network
As a participant in the Coventry Integrated Network, you
need to do the following:
• See referred workers’ compensation patients as soon
as possible.
• Obtain prior authorization when required by applicable
laws from the workers’ compensation payer for
proposed services.
• Communicate treatment plans to injured workers clearly.
• Respond promptly to requests for injured worker status
and medical records.
• Familiarize yourself with the workers’ compensation
payers and accept PPO contract allowable as payment
in full (to avoid balance billing).
• Help Coventry Workers’ Comp Services maintain accurate
information on your practice. (e.g., changes in address,
federal tax identification number, etc.). To do this, you
may call 1-800-937-6824 (TTY: 711). Or go to
CoventryProvider.com and use the update feature.
• Work with Coventry Workers’ Comp Services and its
payers to resolve issues.
• Comply with the requirements on CoventryWCS.com
for filing a complaint or grievance.
• Understand clients’ utilization management and
precertification programs.
• Refer injured workers to other Coventry Workers’
Comp Services providers. To do so, visit
CoventryProvider.com and use the “Referral Search
and Directory Information” link.
• Respond promptly to requests for information
related to recredentialing or database updates.
• Submit bills on behalf of injured workers.
• Encourage injured workers’ return to work as
medically appropriate.
• Report detailed information about the capabilities
and limitations of the injured worker.
• Comply with all requests for verbal and written reports
• Keep informed of current workers’ compensation
regulations.
• Contact your state workers’ compensation agency for
updated treatment/disability management guidelines
and available state training information.
67
Credentialing
All provider credentialing activities are
completed by Aetna. For more details, go to
the “Joining our network” section on page 13.
Billing
Coventry Workers’ Comp Services has partnered with
Jopari Solutions to create a comprehensive end-to-end
eBilling solution. This solution:
• Allows payers to receive bills directly from providers
(via an agent) in an American National Standards
Institute (ANSI) compliant format
• Allows providers to receive basic status of bills being
processed
• Allows providers to receive electronic remittance advice
from payers within required state timelines
• Allows providers to submit appeals and reconsiderations
in paper or electronically
• Is expandable to allow Coventry Workers’ Comp
Services to act as eBill gateway for all client eBill
transactions
• Is expandable to accommodate eBill requirements
for new states as they adopt eBilling requirements
• Wraps around existing client workflow model to
minimize client development and workflow change
Coventry is compliant with all states which require
electronic billing. If you wish to become a Coventry
Workers’ Comp Services eBilling partner, contact
Jopari Solutions at 1-866-269-0554 (TTY:711).
State-specific requirements
Go to CoventryWCS.com find information about
state-specific requirements.
Coventry Auto Solutions
Coventry Auto Solutions offers cost-containment
solutions to assist with the rising medical costs
associated with medical payments resulting from
auto-related injuries. We design best-in-class products
and services to help restore the health and productivity
of parties injured as a result of an auto injury. We
accomplish this by developing and maintaining
consultative, trusting partnerships with our clients,
providers and other stakeholders, built on a foundation
of innovative and customized solutions that support the
claims management process.
Coventry Auto Solutions helps injured parties find
participating providers in the Coventry Integrated Work
®
auto network. Payers and injured parties can visit our
website, CoventryAutoSolutions.com, or call us
toll-free at 1-800-793-6074 (TTY: 711).
A note about steerage: Although payers may not actively
encourage their injured parties to seek treatment through
a Coventry Auto Solutions participating provider, injured
parties may locate you in a variety of ways. These include:
• Through their group health plan
• After being treated by you through Coventry’s network
for a prior workers’ comp injury
• By locating you through an online provider directory
or toll-free number
• By recommendation of a trusted associate or family
member
Contact information and links
Coventry Auto Solutions:
• Phone: 1-800-937-6824 (TTY: 711)
• Website: CoventryAutoSolutions.com
Payer contact information:
• Website: CoventryProvider.com
Client identification
Note: Auto payers do not provide ID cards to insureds.
Providers may access the Client/Payer list on
CoventryProvider.com in order to determine whether
they are participating in the Auto Network for a
particular member.
Claims administration information
Verification of compensability: Verify the injured
party’s compensability status by calling the carrier,
payer or claims administrator.
• Utilization management and precertification:
Contact the carrier, payer or claims administrator
to verify utilization management or precertification
requirements.
• Billing, payment and claims: Provider and clinic
claims for patients are typically billed electronically
or on the CMS-1500 and UB-04 (or successor) forms
and submitted by the provider’s office to a payer.
Incomplete forms or claims sent to the incorrect
address may cause delays in payment.
• Contracted amounts and PPO allowable:
The injured party should not be balance billed for the
difference between the contracted amount and the
total billed charges.
68
• Guarantees of payment, pre-payment agreements
and separate-fee arrangements: Providers should
not enter into separate contracted-amount agreements
with Coventry clients.
• Covered services not medically necessary: Injured
parties will not be billed for services that are
determined to be ‘‘not medically necessary.’’
• Billing follow up: Initial billing follow-up calls should
be made to the carrier, payer or claims administrator.
• Explanation of review (EOR):
- This varies from payer to payer
- For questions related to an EOR, call the Customer
Service telephone number located on the specific EOR
Provider responsibilities
As a participant in the Coventry Integrated Network
SM
,
you need to do the following:
• Obtain prior authorization when required by the auto
payer for proposed services.
• Communicate treatment plans to injured parties clearly.
• Respond promptly to requests for injured party status
and medical records.
• Familiarize yourself with the auto payers and accept
PPO contract allowable as payment in full (to avoid
balance billing).
• Help Coventry Auto Solutions maintain accurate
information on your practice. (For example, changes
in address, federal tax identification number). To do
this, you may call 1-800-937-6824. Or go to
CoventryProvider.com and use the update feature.
• Work with Coventry Auto Solutions and its payers to
resolve issues.
• Comply with the requirements for filing a complaint
or grievance.
• Understand clients’ utilization management and
precertification programs.
• Respond promptly to requests for information related
to recredentialing or database updates.
• Submit bills on behalf of injured parties.
• Comply with all requests for verbal and written reports.
First Health
®
and Cofinity
®
networks
About First Health and Cofinity
Our networks include the First Health Network and
Cofinity Network. First Health is one of the nation’s
largest and most respected preferred provider
organizations. It consists of more than 5,500 hospitals,
over 115,000 ancillary facilities and over 1.5 million health
care professional service locations.
4
Cofinity is a leading
regional network in Michigan and Colorado. You will know
when your patient is a member. One of our network
logos will be on the identification card.
Our relationships with providers are an important part of
our success. We are committed to making sure that you
receive the latest information, technology and tools
available when serving your patients.
First Health serves a wide range of payers, including
third-party administrators, carriers, employers, Taft-Hartley
trusts and government entities. More than 5.5 million
people access the First Health network each year.
We serve the needs of student plans, unions and health
plans, as well as self-insured employer groups and
international payers. Payment policies may differ.
Our provider portal
Our provider portal, FirstHealth.com, allows you
secure access to claims and pricing sheets for First
Health’s networks. You can:
• Search for claims by patient or physician
• View and print pricing sheets
• Research and correct misdirected claims
To register, you will need a tax identification number
(TIN), health plan name and member’s ID number. If you
need help registering, please contact Net Support at
1-866-284-8041.
Eligibility
To get eligibility information, use any of the ways below:
• Phone: call the payer phone number on the member’s
ID card
• Phone: 1-800-937-6824, option 3 (TTY: 711)
• Website: FirstHealth.com
4
First Health and Cofinity. Medical network options. June 2019. First Health Data Warehouse. Available at:
MyFirstHealth.com/1001. Accessed April 27, 2020.
69
Referrals
• Website: to find a participating specialist, use the
“Locate a Provider” button on FirstHealth.com
• Phone: call the payer phone number on the
member’s ID card
• Phone: if you don’t have access to the ID card, call
1-800-937-6824, option 3 (TTY: 711)
Claims submission
• Email: send claims electronically to the payer ID
email address on the member’s ID card
• Mail: use the address on the member’s ID card
• Phone: if you don’t have access to the ID card,
call 1-800-937-6824, option 3 (TTY: 711)
Claims status
· Phone: call the payer phone number on the member’s
ID card
· Phone: if you don’t have access to the ID card, call
1-800-937-6824, option 3 (TTY: 711)
Claims follow up
• Phone: call the payer phone number on the member’s
ID card
• Website: FirstHealth.com
• Phone: if you don’t have access to the ID card or website,
call 1-800-937-6824, option 3 (TTY: 711)
Fee schedules
Access FirstHealth.com, and select the “Request a Fee
Schedule” tab for:
• Current or future fee schedules
• Full or sample schedules
• Single procedure code or range
• Changed values (future only)
Provider services
Call 1-800-937-6824, option 3 (TTY: 711) for:
• All inquiries about the First Health Network
• Demographic updates
• Credentialing or contract requests
• Provider participation verification
Complaints and grievances
Request a copy of the First Health Complaints and
Grievances process.
• Mail: First Health Complaints and Grievances,
3611 Queen Palm Drive, Suite 201, Tampa, FL 33619
• Phone: Provider Services at
1-800-937-6824, option 3 (TTY: 711)
Questions? Go to FirstHealth.com to read the
“First Health Network Provider Reference Guide.”
All registered company, product and service names are the property of their respective owners.
Aetna.com
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©2020 Aetna Inc.
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