Welcome to your provider manual
Your provider resource ........................................................5
Creating a diverse, equitable and safe workplace ........ 5
A word about compliance ................................................. 5
Here to help you.................................................................. 5
Changes and updates ........................................................ 6
Health Equity ...................................................................... 6
New to the Aetna network? ............................................... 6
Local network information ............................................. 6
Provider data demographics .............................................. 7
Updating your data helps patients nd you.................... 7
Medicare and commercial providers .............................. 7
Provider roster requirements............................................ 7
Helpful links ...........................................................................9
Key contacts........................................................................ 10
Electronic solutions .............................................................12
Eligibility and benets inquiry ..........................................12
Patient cost estimator* ......................................................12
Authorization adds, inquiries and updates ....................12
Referral add and inquiry ...................................................13
Claim submissions ............................................................13
Claim disputes and appeals .............................................13
Claim status transactions .................................................13
Rules for electronic submission ......................................13
Electronic payment methods ...........................................14
Online claims Explanation of Benets (EOB)
statements ..........................................................................14
Electronic remittance advice (ERA) ................................14
Capitated providers ...........................................................14
Working through clearinghouse vendors:
transactions by vendor .....................................................14
Our products ....................................................................... 15
Aetna® Benets Products booklet................................... 15
Joining our network ........................................................... 15
How to apply ......................................................................15
Credentialing (and recredentialing) ................................15
Facilities ...........................................................................15
Health care professionals .............................................15
How to check the status of your application ..............15
Radiology accreditation ....................................................15
Provider identication numbers ......................................16
Share your National Provider Identier (NPI).............16
Aetna provider identication number (PIN) ...............16
Accessibility standards and participation criteria .........16
Primary care provider (PCP) responsibilities .............16
Specialty care provider responsibilities ......................16
Physician-requested member transfer.......................16
Medical clinical policy bulletins .......................................17
Compliance ........................................................................18
Nondiscrimination ..........................................................18
Closed panel ...................................................................18
Members rights and responsibilities ...........................18
Advance directives and the Patient Self-
Determination Act (PSDA) ............................................18
Informed consent ...........................................................19
Transparency: Physician-member
communications policy .....................................................19
Verifying member eligibility and benets .......................20
How to interpret a member ID card ...............................20
Member identication and verication of eligibility.....20
Digital ID cards ..............................................................20
Member ID cards ..........................................................20
Group enrollment form .................................................20
Newborn enrollment .........................................................21
Verifying benets ............................................................... 21
Verifying your network participation ...............................21
Precertication ...................................................................22
Emergencies .......................................................................22
Medical emergencies ...................................................... 22
Follow-up care after emergencies ................................. 22
Claims and billing ...............................................................22
Member billing .................................................................. 22
Billing members for noncovered services—
consent requirements .................................................. 22
Billing and balance-billing members ......................... 23
Other billing situations .................................................. 23
Initiating a collection action against a payer ............. 23
Concierge medicine ..................................................... 23
Claims information ........................................................... 24
Electronic claims submission ...................................... 24
Claims submission tips ................................................. 24
Disagree with a claim decision? ................................. 24
Claims addresses .......................................................... 24
Clean claims .................................................................. 25
Coordination of benets .................................................. 25
Coordination of benets with
commercial carriers ...................................................... 26
Coordination of benets with Medicare .................... 26
Medicare coverage ....................................................... 27
Medicare estimation ..................................................... 27
Medicare and Medicaid dual eligibles ....................... 27
Medicare Part D plans .................................................. 27
Coordination of benets with automobile
insurance/no-fault benets ......................................... 28
The National Advantage™ Program .............................. 28
Coding ................................................................................ 28
Claims payment policy — rebundling ........................... 28
Overpayment ..................................................................... 28
Diagnosis-related group (DRG) ...................................... 28
A DRG interim bill .......................................................... 28
DRG Review ................................................................... 28
Audits ...................................................................................29
Hospital bill audit .............................................................. 29
Outpatient Validation Audits ........................................... 29
Implant audit ..................................................................... 29
Prepay review .................................................................... 29
OrthoNet ............................................................................ 29
Where to send Aetna® records ....................................... 29
Medical records ..................................................................30
Record keeping .................................................................30
Participating practitioner medical record criteria ....30
Organization ...................................................................30
Examination .................................................................... 32
*FOR PATIENT COST ESTIMATOR: Does not apply to any Aetna Medicare Advantage plans.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of
companies, including Aetna Life Insurance Company and its affiliates (Aetna).
2
Studies ............................................................................ 32
Communication ............................................................. 32
Records maintenance and access ................................ 32
Maintenance .................................................................. 32
Member record access ................................................ 32
Privacy practices ............................................................... 33
Referrals .............................................................................. 34
Referral policies .................................................................34
Referral requirements...................................................34
When referrals are not required ................................. 34
Notice and termination .................................................34
Member’s consent for nonparticipating
providers’ referrals ............................................................ 35
Referral processes ........................................................ 35
Utilization management ....................................................35
Overview ............................................................................ 35
Utilization management and standards ........................35
How to contact us about utilization
management issues .........................................................36
Utilization review policies .................................................36
How we determine coverage..........................................36
Admissions protocol ......................................................... 37
Notify us of hospital admissions within
two business days ............................................................ 37
All-products precertication list ..................................... 37
Member programs and resources .................................. 38
Member programs ...........................................................38
Care management ........................................................38
Disease management ..................................................38
Aetna® Healthy Lifestyle Coaching program ............38
Aetna® Lifestyle and Condition Coaching
program ..........................................................................39
Fitness programs for Aetna Medicare Advantage
members ........................................................................39
Aetna Women's Health Program ................................39
Member resources ...........................................................39
24-Hour Nurse Line ......................................................39
Institutes of Excellence® network ........................... 39
Institutes of Quality® designation ............................39
Aetna Institutes® Gene-based, Cellular and
Other Innovative Therapies (GCIT®)
Designated Networks ...................................................39
Behavioral health ..............................................................39
Behavioral Health Accessibility standards* and
participation criteria ......................................................40
Behavioral Health Screening Programs ....................40
Complex Case Management ......................................40
The Aetna® Depression in Primary Care Program ...40
Screening, Brief Intervention and Referral to
Treatment (SBIRT) practice ..........................................41
The Aetna Opioid Overdose Risk
Screening Program ........................................................41
D-SNPs screening for coexisting behavioral
health and substance use disorders ...........................41
Pharmacy management and drug formulary ................42
Overview of the Pharmacy Plan
Drug List (formulary) ........................................................ 42
Commercial plans .........................................................42
Aetna Medicare Prescription Drug Plans ..................42
Requirements for Part B drugs ....................................... 42
How your patients can learn more ............................. 42
Treating complex diseases and
chronic conditions ........................................................43
Ordering through CVS Specialty is easy ...................43
Electronic prescribing .................................................43
Pharmacy clinical policy bulletins ..................................43
Precertication .................................................................. 43
Step therapy ......................................................................43
Quantity limits....................................................................44
Generic drugs ....................................................................44
Medical exception and precertication..........................45
Performance programs .....................................................46
Quality, accreditation, review and
reporting activities ............................................................46
Aexcel® network of specialist doctors ...........................46
Patient-centered medical home (PCMH) .....................46
Physician pay for performance (P4P) ........................ 47
Clinical medical management ......................................... 47
Clinical practice and preventive service guidelines ....47
Clinical practice guidelines .............................................48
Behavioral health clinical practice guidelines ..............48
Preventive services guidelines .......................................48
Case management ...........................................................48
Coordination of care ..........................................................49
Importance of collaboration ............................................49
Sharing patient information .............................................49
Accessing communication forms ..................................49
Transition of care ..............................................................49
The four steps for requesting transition of care .......50
Complaints and appeals....................................................50
Medicare .............................................................................. 51
Aetna Medicare Advantage plans* .................................51
Aetna Medicare health maintenance
organization (HMO) plans and Aetna Medicare
HMO Prime plans ...........................................................51
Aetna Medicare HMO plans with open access .........51
Aetna Medicare preferred provider
organization (PPO) plans and Aetna Medicare
PPO Prime plans ............................................................51
Aetna Medicare Advantage plans
(HMO and PPO) ..............................................................51
Aetna Medicare Advantage HMO plan .......................51
Aetna Medicare Advantage PPO plan
........................51
Home assessment program ........................................... 52
Quality improvement program .......................................52
Medicare prescription drug plan ................................... 52
Transition-of-coverage (TOC) policy .......................... 53
Additional prescription drug plan information ............. 53
Preferred pharmacies ..................................................54
Part D drug rules ...........................................................54
Home infusion ...............................................................54
Additional Aetna Medicare Advantage information ....55
Physician-member communications policy .............55
Demographic data quarterly attestation ....................55
Collecting all Aetna Medicare Advantage plan
member cost sharing ...................................................55
Access to facilities and records ..................................56
Access to services ........................................................56
*FOR BEHAVIORAL HEALTH ACCESS STANDARDS: unless state requirements are more stringent.
*FOR AETNA MEDICARE ADVANTAGE PLANS: 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 52 of this manual, for further information.
3
Medicare Outpatient Observation Notice
(MOON) requirement ...................................................56
Medicare Medical Loss Ratio (MLR)
requirements .................................................................56
Advance directives ........................................................56
MA Organization Determination (OD) process ......... 57
Ban of Advance Beneciary Notice of Noncoverage
(ABN) for Medicare Advantage (MA) ......................... 57
Medicare prescription drug plan
(PDP and MAPD) coverage
determinations and exceptions process ...................58
Medicare Advantage (MA and MAPD) and
Medicare PDP member grievance and
appeal rights ..................................................................58
Obligation to respond to requests for records .........59
Condentiality and accuracy of member records... 59
Coverage of renal dialysis services for Medicare
members who are temporarily out-of-area ..............59
Direct access to in-network women’s health
specialists .......................................................................59
Direct-access immunizations ......................................59
Emergency services .....................................................60
Health-risk assessment ................................................60
Receipt of federal funds, compliance with federal
laws, and prohibition on discrimination .....................60
Provider terminations ...................................................60
Financial liability for payment for services ................60
Medicare Compliance Program requirements .........61
Standards of Conduct and Compliance policies ......61
Exclusion list screening .................................................61
Oversight of your subcontractors ................................61
What may happen if you don’t comply .......................61
Making sure you maintain documentation ................61
Report concerns or questions ......................................61
Special Needs Plans (SNPs) Model of Care ...............61
The Patient Protection and Aordable Care Act
(PPACA), implemented in 2010 ................................... 62
The “eective communication” baseline rule ........... 62
Individuals qualifying for auxiliary supports
and services ................................................................... 62
Auxiliary support and service options ....................... 62
Persons qualied to act as interpreters .................... 62
Medicare Access and CHIP Reauthorization Act
(MACRA) reimbursement policy ................................. 63
Temporary move out of the service area ..................63
Travel programs — when members are away
from home for an extended period ............................63
Plans rules and requirements must be followed .....64
Urgently needed services ............................................64
Physicians and other health care professionals and
marketing of Aetna Medicare Advantage plans ......64
Annual notice of change ..............................................64
Claims and billing requirements .................................65
Submitting Medicare claims and encounter data
for risk adjustment ........................................................65
Risk adjustment medical record validation ...............65
Providers of hospice-related services .......................66
Centers for Medicare & Medicaid Services (CMS)
physician incentive plan: general requirements ......66
CMS physician incentive plan: substantial
nancial risk ................................................................... 67
CMS physician incentive plan: stop-loss
protection requirements .............................................. 67
Aetna Medicare Advantage organization (MAO)
obligations ...................................................................... 67
Permissible activities .................................................... 67
What contracted providers may do............................68
Ambulance services .....................................................68
Rights and responsibilities for Aetna Medicare
Advantage HMO and PPO plan members with a
prescription drug benet ................................................68
Rights ..............................................................................68
Responsibilities .............................................................. 70
Rights and responsibilities for Aetna Medicare
Advantage HMO and PPO plan members without
a prescription drug benet ............................................. 70
Rights .............................................................................. 70
Responsibilities ...............................................................71
First Health
®
and Conity
®
networks ................................. 72
About First Health and Conity....................................... 72
Our provider portal .......................................................... 72
Eligibility .......................................................................... 72
Referrals .......................................................................... 72
Claims submission ........................................................ 72
Claims status .................................................................. 73
Claims follow-up............................................................ 73
Fee schedules ................................................................ 73
Provider services ........................................................... 73
Complaints and grievances ......................................... 73
Behavioral Health ............................................................... 74
Our programs .................................................................... 75
Clinical delivery ................................................................ 76
Quality programs ............................................................. 83
Working electronically with us .........................................87
Appendix A: Aetna® Behavioral Health treatment
record review criteria and best practices .......................89
4
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,
including but not limited to, reimbursement policies.
For instance non-physician practitioners, behavioral
health care providers and other qualified health care
practitioners payment methodology may differ
depending on licensure and applicable law. 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 prior 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.
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.
Here to help you
This manual is for you — physicians, hospital medical
and facility staff, and 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.
5
Changes and updates
When things change, we’ll let you know
You are required to provide us with your email address so
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
Aetna OfficeLink Updates
TM
, our provider newsletter. If
your office hasn’t heard from us or your contact
information has changed, you must 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.
Learn more
• Read Aetna OfficeLink Updates on Aetna.com, in the
Providers section.
• Review Provider data demographics in
this document.
Health Equity
Aetna is committed to reducing health disparities and
improving the health of all communities. The quality of
the patient-provider relationship plays an influential role
on patient outcomes. According to the Journal of the
American Medical Association, health disparities and
inequities are linked to a lack of racial and ethnic
similarity or shared identity between providers and
patients.* We’re encouraging providers to voluntarily
identify their race and ethnicity for Aetna® members to
use in our provider online directory.
Here is how to update your race and ethnicity
information
Through the Availity portal, you can now voluntarily
update your languages spoken, race and ethnicity. Our
members rely on accurate information in our online
provider directory when seeking medical services. We
hope you continue to help us provide our members with
accurate and complete information.
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
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.
*FOR HEALTH DISPARITIES SOURCE: Takeshita J, Wang S, Loren A, et al. Association of racial/ethnic and gender
concordance between patients and physicians with patient experience ratings. JAMA Network Open.
November 9, 2020; 3(11). Accessed April 5, 2022.
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.
6
Provider data demographics
Federal and applicable state law requires Aetna® and
providers to work together to maintain accurate provider
directory lists.
It is required by law for you and Aetna to keep your
information current and to confirm its accuracy at least
every ninety (90) days. However, Aetna may require
confirmation upon request as well.
Updating your data helps patients find you
We include provider data information in our directories to
help patients find care. Being in our directories allows
new patients to find out if you are accepting new
patients, where you’re located, and how to reach
you. In addition, by making sure we have your current
information, we can send you timely communications
and reminders.
Remember to notify us of your data changes in accordance
with state, federal, and contractual requirements and
guidelines. Failure to do so will result in corrective action in
accordance with applicable law.
Continue reading to learn how to update your information.
Medicare and commercial providers
Go to Availity.com to update your information. (If you
can’t use Availity.com, submit a Request Changes to
Provider Data Submission Form found on Aetna.com)
Here are some examples of what you can update:
• Primary address indicator
• Service location address
• Provider name
• Appointment phone
• Accepting new patients
• Specialty
• Handicap accessibility
• Office hours
• NPI
• Gender
• Language
• Board certification
• Education/degree
• Hospital affiliation
• Office staff language
• Race
• Ethnicity
Provider roster requirements
This section outlines the standards and requirements for
any Delegated Credentialing provider group or other
provider groups approved by us to submit a roster of
providers or provider updates to us, so we can upload
the information into our systems.
A Delegated Credentialing Entity or Delegate is a
hospital, group practice, credentials verification
organization (CVO) or other entity that we have given
the authority to perform specific provider credentialing
functions. When credentialing responsibilities are
delegated to you, you are known as the Delegated Entity.
1. Roster data quality
The information contained on rosters directly impacts
our provider directories and other systems (for
example, claim payment systems) and must be
maintained, completed and accurate in accordance
with applicable law.
We reserve the right to analyze and score each roster
received and will return poor-quality rosters for
correction and resubmission to us.
Continued submission of poor-quality roster
information may result in:
a. A request for corrective action
b. Omission of providers from the search tool
c. Our refusal to accept any further rosters from your
group
d. A requirement for your group to maintain
demographic data through other means (such as
through Availity)
e. Termination of Delegated Entity status
7
2.Provider roster submission requirements
Delegates or other groups who are approved by us to
submit rosters are required to:
a. Submit a complete and accurate roster in Excel or
similar columnar format. (Word and PDF files are
not acceptable.)
b. Include all necessary roster fields on submissions.
(For examples, see the "Roster fields" section.)
To get a roster template, email us and put
“Roster template request” in the subject line.
c. All providers must submit information monthly and
quarterly, as described in the bullets. (If you
already submit information more frequently, please
continue to do so. If you want to start submitting
more frequently, please do so.)
Minimum required submissions:
• A monthly roster with adds, changes and
deletions
• A quarterly full roster that includes all providers
d. Contact each provider in your network at least
once a quarter to validate that their demographic
information is correct.
3. Roster fields
The roster shall contain separated fields for each
element. This includes but is not limited to the
following elements:
a. Provider information
• Date of birth
• Degree
• Ethnicity
• Gender
• Practice name
• Provider first name
• Provider last name
• Provider middle initial
• Race
• Role (primary care provider, specialist, or both)
• Provider language (if other than English)
b. Licenses and identification numbers
• Board certification (board name, effective date,
and expiration date)
• Controlled dangerous substance (CDS)
expiration date
• Controlled dangerous substance (CDS) number
• Credentialing date (most recent)
• Credentialing date (original)
• Medicare expiration date
• Medicare number
• National Provider Identifier (NPI) number
• National Provider Identifier (NPI) type
• State license effective date and expiration date
• State license number
• State license state of issue
• Tax ID number
• Tax ID owner name
• U.S. Drug Enforcement Administration (DEA)
registration number
• U.S. Drug Enforcement Administration (DEA)
registration number expiration date
• U.S. Drug Enforcement Administration (DEA)
state of issue
c. Service contact information
• Service location appointment phone number
• Service location email
• Service location fax number
• Service location street address
• Service location suite number
• Service location city
• Service location state
• Service location ZIP code
• Primary location (Y or N)
d. Services provided
• Accepting new patients (Y or N)
• Accessible to persons with disabilities (Y or N)
• Ages treated
• Languages spoken by staff
• Office hours
• Specialty
• Directory print (Y or N)
e. Billing information
• Billing location street address
• Billing location suite number
• Billing location city
• Billing location state
• Billing location ZIP code
• Billing location phone number
• Billing location fax number
8
Helpful links
Here are the websites to use to access related content and information.
Website Link
Aetna® Aetna.com
Aetna Compassionate Care℠ program AetnaCompassionateCare.com
Aetna Medicare Advantage Medicare Resources for Providers
The Aetna medication search tool (formulary) https://fm.formularynavigator.com/FBO/41/2022_
Advanced_Control_Plan_Aetna_.pdf
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 program https://www.aetna.com/services/womens-health.
html
CAQH® CAQH.org
Drug formularies Aetna.com/health-care-professionals/clinical-
policy-bulletins/pharmacy-clinical-policy-bulletins.
html
eviCore healthcare eviCore.com
First Health and Cofinity https://providerlocator.firsthealth.com/
LocateProvider/SelectNetworkType
Harvard Health Health.Harvard.edu
Online referral search tool https://www.aetna.com/individuals-families/
find-a-doctor.html
9
Key contacts
Here are the numbers to call for questions or requests on behalf of your patients.
Department Contact information
Provider Contact Center
• Claim inquiries and questions
• Member eligibility and benefits
• Patient management
• Precertification
1-800-624-0756 (TTY: 711) for Aetna Medicare
Advantage plans and HMO-based plans
1-888-MDAetna (1-888-632-3862) (TTY: 711) for all
other plans
24-Hour Nurse Line 1-800-556-1555 (TTY: 711)
Aetna Credentialing Customer Service 1-800-353-1232 (TTY: 711)
Aetna Health Connections℠ Disease Management
program
1-866-269-4500 (TTY: 711)
Aetna Signature Administrators® Refer to the member ID card.
Aetna Student Health℠ plans Visit our website.
Aetna voluntary plans and the 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) Refer to the member ID card.
Behavioral health (provider services) 1-888-632-3862 (TTY: 711)
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)
CVS Caremark® Mail Service Pharmacy • Phone: 1-888-792-3862 (TTY: 711)
• Fax: 1-800-378-0323
CVS Specialty® Phone: 1-800-237-2767 (TTY: 711)
Visit our website.
eviCore healthcare 1-888-622-7329 (TTY: 711)
10
Department Contact information
Dispute submission
Write to the PO box l
isted 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.
Note: The information is also available on our
provider portal on Availity.
1-800-624-0756 (TTY: 711) for Aetna Medicare
Advantage plans and HMO-based plans
1-888-MDAetna (1-888-632-3862) (TTY: 711) for all
other plans
Note: When you call, have the EOB statement and the
original claim handy.
Enhanced clinical review program eviCore healthcare
1-888-622-7329 (TTY: 711)
Infertility program 1-800-575-5999 (TTY: 711)
Medicare expedited organization determinations
(EODs)
Aetna Medicare Advantage plans
Standard requests
• Phone: 1-800-624-0756 (TTY: 711)
Expedited requests
• Submit the request via electronic data
interchange (EDI)
• Phone: 1-800-624-0756 (TTY: 711)
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
Part B precertification:
• Phone: 1-866-503-0857 (TTY: 711)
• Fax: 1-844-268-7263
• Website: Availity.com
SilverScript® Part D plan • Phone: 1-866-235-5660
• Fax: 1-855-633-7673
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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
Authorization adds, inquiries and updates
Our Authorization Add and Authorization Inquiry
transactions are quick, easy ways to request or check
the status of an authorization. Benefits include:
• The ability to access all Aetna® benefits plans 24 hours
a day, Monday through Saturday
• The ability to determine if medical authorization is
required via the precertification code search tool
• The ability to confirm whether a valid authorization
is present or not and to check the status of previously
submitted requests (for pended requests, we will
respond with a detailed status, so you can see our
progress in processing your request)
• The ability to make updates (for Commercial members
only) to an authorization before the date of service
through our provider portal on Availity
Complete an Authorization 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 and create a new request once a decision
has been made
• Add up to five new diagnosis codes or a note in the
comments field (there is space for 264 characters), and
create a new request once a decision has been made
• Update or change admission details prior to service,
such as changing the admit date or adding a discharge
(once the service has begun, changes to the existing
dates and procedures cannot be made)
• Add, update or cancel up to five procedure codes
and the associated details (for Medicare members,
submit a new request)
• Make additional changes such as adding an end date to
an initial request, as long as the request isn't more than
180 days from the date of service (once the service has
begun, do not change existing dates and procedures)
• Submit clinical information in support of pending and
new authorization requests and open concurrent review
cases (create a new request once a decision has been
made and, once a decision has been made, do not
cancel or void procedures and services)
Providers can upload supporting information (such as
medical records or additional information forms) through
our provider portal on Availity using the Authorization
Submission or Authorization Inquiry transaction. Users
can upload up to six electronic files at a time, with a size
of 32MB per file, 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)
The files 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.
*FOR PATIENT COST ESTIMATOR: Does not apply to any Aetna Medicare Advantage plans.
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For certain procedures, you may be asked to complete
a clinical questionnaire to provide additional clinical
information. Answer the questions, and you may
receive an immediate approval.
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
Claim 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.
Claim disputes and appeals
For commercial and Medicare claims, submit your
electronic appeal, reconsideration, and rework requests
by any of the ways below. (Both use the same time
frame requirements.)
1. Provider portal
A claim must be in Finalized status before you can
dispute it.
To dispute a claim, complete a "Claim Status transaction"
and select the claim you want. If it is in Finalized status,
there will be a "Dispute Claim" button. Click it and upload
any supporting documentation. Then click "Submit."
Note: Due to technical reasons, you may not be able to
dispute all claims on the provider portal. The portal will
tell you when you can't dispute a claim on it. If that
happens, to dispute a claim, go to the Disputes and
appeals page our website.
2. Our website
Use the Dispute and appeals process FAQs
page on our website to learn about the process
and get links to the forms you need.
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
• On our provider portal, to initiate a claim
dispute — in Claim Status Response, just click on
the Dispute Claim button
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:
• Authorization (also called precertification)
• Claims Status Inquiry
• Eligibility and Benefits Inquiry
• Referrals
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Electronic payment methods
Providers must enroll in order to receive deposit
payments by electronic funds transfer (EFT). Providers
who do not enroll to receive direct deposit payments may
receive virtual credit card (VCC) payments. Visit our
website for more information and to access our portal
— where you can enroll and make changes.
EFT allows you to 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*
When you receive EFT payments, we will assign each
payment a unique trace number. If you are not enrolled
to receive electronic remittance advice (ERA), you can
retrieve electronic copies of our Explanation of Benefit
(EOB) statements from our provider portal. Use the same
trace number to view or download EOB statements.
If you do not enroll in EFT, we may enroll you to receive
payments by virtual credit card (VCC). VCC payments
work in the same way as processing credit card
payments without having the card present. Processing
payments is a simple two-step process:
1. First, you will receive an Explanation of Payment (EOP)
printed with a 16-digit card number.
2. Then you can manually enter the number and the full
amount of the payment into your credit/debit point of
sale (POS) terminal before the card’s expiration date.
You will receive your funds in the same time frame as you
get other credit card payments today. We do not charge
a fee to enroll in or to accept VCC payments. You will just
pay your standard merchant fees, like any other credit
card payment you process through your POS terminal.
You may choose to disenroll from VCC, but you must
enroll in EFT first and agree to process any outstanding
VCC payments.
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
• View, download and save as a PDF, or print EOB
statements
• Use the Remittance Viewer tool on our provider portal
to get Explanation of Benefits (EOB) statements. You
can search for EOB statements using the:
- Check or electronic finance transaction (EFT)
trace number
- National Provider Identifier (NPI)
- Payer name
- Tax ID
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)
When you receive both ERA and EFT, your trace number
will be the same for both your ERA file and your EFT.
Visit our website for more information and to access
our portal — where you can enroll and make changes.
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 us 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.
*FOR EMAIL: EFT email notifications are not available for VCC payments.
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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
You 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), 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 on-site
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 we use CAQH ProView to get your
credentialing application, unless otherwise required by
state regulation
• If you’re a physician located in Arkansas we use the
ARCCVS
How to check the status of your application
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
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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
Providers are required to comply with Aetna participation
requirements, which are available 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, which are listed in our participation criteria,
along with other PCP criteria.
Specialty care provider responsibilities
We have standards for member access to specialty care
services. Each specialty care provider is required to have
appointments available, in person or via telehealth, within
these time frames:
• Routine care: within 30 business days
• Urgent/emergent matter: immediately or referred to the
emergency room, as appropriate
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. More stringent state
requirements supersede these accessibility standards and
are located in the Provider Manual State Supplement.
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
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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. CPBs apply to all
Aetna medical benefit plans and are used in conjunction
with the terms of the member’s benefit plan and other
Aetna-recognized criteria to determine health care
coverage for our members. 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” and “medical necessity” refer 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 in terms of type,
frequency, extent, site, place of service, duration, and
considered effective for your illness, injury or disease
• 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.
Please note, each state may have its own definition of
“medically necessary” or “medical necessity.” You may
be required to adhere to those standards imposed by the
state’s definition based on the state you practice in.
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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.
Please refer to the participation criteria with respect to
telehealth accessibility standards for members with
disabilities. You're required to conform to all such
standards as well as any additional applicable federal
and state disability laws.
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.
Closed panel
Participating providers must notify us if they are not
accepting our members as new patients. To prevent
discrimination our expectation is that participating
providers will not accept new patients from a competitor
while they are not accepting our members as new
patients.
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.
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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
Transparency: Physician-member
communications policy
In accordance with applicable law (e.g., federal “Price
Transparency”), our contracts do not prevent participating
providers from disclosing rate or payment information
when required. They also do not contain clauses that
“gag” or prevent Aetna or payers from disclosing price,
quality, and other information in violation of applicable law.
We encourage providers to discuss issues openly with
their patients. We want our members to have the comfort
of knowing their providers have the right and obligation
to speak freely with them. Providers should 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 procedure
• The potential risks and benefits of any
recommended treatment
• Any reasonable alternatives to such
recommended treatment
Federal Continuity of Care requirements
In addition to state law, the federal “No Surprises Act”
requires compliance by terminated Providers with its
continuity of care requirements.
The Federal Continuity of Care requirements apply
to members who are continuing care patients,
meaning they are:
• Undergoing a course of treatment for a serious and
complex condition;
• Undergoing a course of institutional or inpatient care;
• Scheduled to undergo non-elective surgery from the
provider, including receipt of postoperative care from
such provider or facility with respect to such a surgery;
• Pregnant and undergoing a course of obstetrical
treatment for the pregnancy;
• Determined to be terminally ill (if the individual
has a medical prognosis that the individual’s life
expectancy is 6 months or fewer) and receiving
treatment for such illness.
A continuity-of-care triggering event occurs, if, while a
member is a continuing care patient:
• The provider contractual relationship with Aetna
is terminated;
• Benefits provided under the health plan are terminated
because of a change in the terms of the participation of
the provider in the health plan; or
• The contract between the plan sponsor and Aetna is
terminated, resulting in a loss of benefits provided
under the plan.
Providers cannot balance bill members who are
continuing care patients for more than their in-network
coinsurance, cost share or deductible rate.
Providers must also continue to accept, as payment in
full, the rates in the services and rate schedule that were
in effect prior to termination.
Several states also have continuity/transition of care
requirements that are applicable to fully insured
Members. In these situations, the federal requirements
are applied first with state requirements filling in any
potential gaps (e.g., balance billing). If the federal and the
state requirements conflict, the better benefit for the
member will be applied.
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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, 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.
- 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℠
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.
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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.
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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.
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.
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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 bill or balance bill members in situations including
but not limited to the following:
• 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 member is incorrectly billed, balance billed or
overcharged, we ask you to remedy the situation, and
if necessary promptly refund the member. 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.
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.
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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.
• If you don't already have an electronic claims 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. You can also submit attachments we
don't ask for (unsolicited) through our provider portal
and selected claims vendors. View our list of
participating vendors to see which vendors allow
electronic unsolicited attachments through the
claims attachment transaction (X12N 275).
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?
Initiate a claim dispute by using any of the ways below.
• Online
If you are registered for our provider portal, submit a
Claim Status Inquiry transaction. If the claim is eligible
to dispute, you'll see a Dispute Claim button. (Read
more about how dispute a claim online in the
“Electronic solutions” section.)
• Mail
Write to the PO box that's listed on the EOB statement
or the denial letter related to the issue being disputed.
In your letter, include the reasons for the disagreement,
• Phone
Call our Provider Contact Center (see Key Contacts on
page 10).
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
• For all Aetna Medicare Advantage and Aetna
Student Health℠ 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, Meritain
Health® and Schaller Anderson (Medicaid), refer to the
member ID card.
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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
Coordination of benefits (COB) establishes the order in
which benefits are paid and the amount by which the
secondary plan may reduce its benefits. COB ensures
that the combined payments of all plans do not add up to
more than the covered health care expenses.
We coordinate benefits as allowed by state or federal law
following the National Associations of Insurance
Commissioners (NAIC) guidelines. If there is no
applicable law, then we coordinate according to the
member’s plan.
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
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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
Aetn
a will pay the
difference between the
primary plan’s benefit
and the Aetna benefit
Coordination of benefits with
commercial carriers
We follow the National Association of Insurance
Commissioners (NAIC) Order of Benefits Determination
(OBD) rules to determine which plan pays primary.
Refer to Section 6 “Rules for Coordination of Benefits” in
the NAIC Coordination of Benefits Model Regulation
document for OBD rules.
Below are examples of the most common rules:
• COB Rule vs. No COB Rule
• Non-Dependent/Dependent Rule
• Dependent on Spouse’s Plan and Dependent on
Parent’s Plan(s) Rule
• Dependent Child/Parents Not Separated or Divorced
Rule (Birthday Rule)
• Dependent Child/Parents Separated/Divorced/Not
Living Together Rule
• Active/Inactive Employee Rule
• Continuation Rule (also known as COBRA)
• Longer/Shorter Rule
Coordination of benefits with Medicare
When a member has Medicare in addition to an Aetna
group policy, we follow the Center for Medicare &
Medicaid Services (CMS) guidelines to determine if
Aetna or Medicare pays primary. Learn more about
How Medicare works with other insurance
and how coverage is affected because of
End-stage renal disease (ESRD).
Below are examples of the most common rules:
Aetna
coverage
type
Medicare due
to disability
(under age 65)
Medicare due
to age
(65 and over)
Ac
tive poli
cy
(active
employment)
Aetna policy
has 100 or
more
employees:
• Aetna primary
• Medicare
secondary
Aetna policy
has 20 or more
employees:
• Aetna primary
• Medicare
secondary
Active policy
(active
employment)
Aetna policy
has 99 or fewer
employees:
• Medicare
primary
• Aetna
secondary
Aetna policy
has 19 or fewer
employees:
• Medicare
primary
• Aetna
secondary
Inactive policy
(retiree,
disabled,
COBRA)
• Medicare
primary
• Aetna
secondary
• Medicare
primary
• Aetna
secondary
Medicare is the secondary payer to group health plans
(GHPs) for individuals entitled to Medicare based on
end-stage renal disease (ESRD) for a coordination period
of 30 months, regardless of the number of employees
and whether the coverage is based on current
employment status.
Aetna coverage type Medicare due to
end-stage renal
disease (ESRD)
Active Policy (Active
Employment)
• Aetna policy primary for
coordination period
• Medicare primary after
coordination period
Inactive Policy (Retiree,
Disabled, COBRA)
• Aetna policy primary for
coordination period
• Medicare primary after
coordination period
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Medicare coverage
Traditional Medicare has two parts: Medicare
Part A and Medicare Part B.
Medicare Part A provides coverage for:
• Inpatient care in a hospital
• Skilled nursing facility care
• Hospice care
• Home health care
Medicare Part B provides coverage for physician
and laboratory services.
Medically necessary services: Services or supplies
that are needed to diagnose or treat your medical
condition and that meet accepted standards of
medical practice.
Preventive services: Health care to prevent illness
(like the flu) or detect it at an early stage, when
treatment is most likely to work best.
Part B covers things such as:
• Clinical research
• Ambulance services
• Durable medical equipment (DME)
• Mental health
- Inpatient
- Outpatient
- Partial hospitalization
• Limited outpatient prescription drugs
Most people do not pay a monthly premium for
Medicare Part A coverage since they have paid
Medicare taxes while working. Their Medicare
Part A coverage is automatic.
Enrollment in Medicare Part B is voluntary. Eligible
enrollees must pay monthly premiums for Medicare
Part B. If an eligible member does not enroll in Part B
when they are first eligible, they may have to pay a
late enrollment penalty.
If you enroll for Part A and Part B during your initial
enrollment period, your coverage will start the first day of
the month you become eligible based on your birthdate,
disability date or dialysis date.
Medicare Advantage plans, sometimes called “Part C” or
“MA plans,” are an “all in one” alternative to traditional
Medicare, administered by private insurance companies.
These “bundled” plans include Medicare Part A and
Part B coverage and often include drug coverage,
known as Medicare Part D.
Enrollment in Part C replaces the enrollment for
Medicare Part A and Part B.
Costs for Medicare Advantage plans vary based on plan
design and geographical area.
Medicare estimation
When a member is eligible for Medicare Part B but does
not enroll in Medicare, we may estimate Medicare’s
benefits and coordinate with the estimated amounts. We
will estimate benefits when allowed by state legislation or
when elected by the plan sponsor.
It is important for members to enroll, as estimation of
Medicare benefits leaves the member with higher
cost-share amounts.
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.
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 (MAPDs). 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.
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Coordination of benefits with automobile
insurance/no-fault benefits
We coordinate benefits with personal injury protection
(PIP) as allowed by state or federal law following the
National Association of Insurance Commissioners (NAIC)
guidelines. If there is no applicable law, then we
coordinate according to the member’s plan. Our
standard fully insured plans prohibit COB with no-fault
automobile insurance. We do not coordinate with
no-fault/auto insurance:
• When state law prohibits COB with no-fault
• When states don’t have a no-fault law
Self-funded plans follow the COB provision in the plan
sponsor contract.
The National Advantage™ Program
The National Advantage Program (NAP) provides medical
cost management on covered services that are not
provided within the network.
If member's plan includes the NAP, Aetna may apply the
commercial product rates. Not all member ID cards for
plans that participate in NAP include its logo.
Under NAP, providers may only bill for copayment,
coinsurance, or a deductible.
Coding
As changes to coding are published by nationally
recognized coding entities, we will update our internal
systems and practices, as appropriate. Updates may
include assignment/reassignment of codes to service
groupings and/or other updates that are consistent with
Aetna® policies and applicable law. Until any updates are
complete, services may be subject to the standards and
coding set for the prior period. The rates and
compensation under your agreement are subject to the
Aetna coding/claim edit policies, procedures and
practices (e.g., DRG assignment), which may be updated
from time to time, and which may consider actual
services performed and the setting in which they
are provided.
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
When Aetna, payer and/or member has been
overcharged you are obligated to promptly reprocess the
claim. For commercial plans, company will notify the
provider of overpayment typically within 24 months of the
original payment issue date or other time frame required
by applicable law.
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.
Diagnosis-related group (DRG)
A diagnosis-related group (DRG) is the most widely used
strategy for classifying acute care hospital patients and
measuring the case mix. The most common principal
diagnosis is the condition primarily responsible for the
admission of the patient to the hospital for care.
Our payment policies are designed to help us pay
providers based on the code that most accurately
describes the procedures/services that were performed.
A DRG interim bill
An interim bill (also known as a split bill) allows a hospital
to submit a claim for a portion of the patient’s hospital stay.
We will reimburse the first interim bill from a facility with a
DRG payment methodology, based on the admitting
information, and will reimburse the balance when we
receive the final bill.
DRG Review
Claims billed with a DRG may be reviewed on a pre-pay
or post-pay basis through a medical record review
process. In this case, once the medical record review
process is complete, a narrative and proposed DRG
revision is sent to the provider, at which point we have
opportunities to address disagreements. A DRG
short-stay review is a post-service, post-payment review
of Medicare risk inpatient claims paid under a DRG
methodology. This review is done to validate that the
provider appropriately billed and received payment for
the setting of care in which the patient was treated.
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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 percentage of billed dollars (charges).
Outpatient Validation Audits
Outpatient Coding Audits performed by clinical coders
verify the code assignment and reimbursement using
medical records. The savings is based on the medical
record review, audit overpayment findings and recovery
of those dollars.
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 review
As allowed by law, 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. The itemized bill
review may also occur on a post-payment basis.
OrthoNet
We use OrthoNet to review our members’ medical
records before certain claims are processed. When a
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
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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 require 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, ethnicity,
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 on all pages
- 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
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.*
*FOR ENTRY REQUIREMENTS: This is assessed for Medical Record Keeping Practices based on guidelines from the
National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS), insurance
regulations and Aetna.
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- 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 use 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 use 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.
• 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
*FOR ENTRY REQUIREMENTS: This is assessed for Medical Record Keeping Practices based on guidelines from the
National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS), insurance
regulations and Aetna.
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32
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)
for the purpose of making decisions around treatment,
payment or health plan operations.
* FOR ENTRY REQUIREMENTS: This is assessed for Medical Record Keeping Practices based on guidelines from the
National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS), insurance
regulations and Aetna.
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 require our participating physicians, facilities, and
office staff to safeguard their patient's PHI, and treat it
with the same care and consideration.
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
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.
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34
Referrals
Referral policies
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. In benefits plans
that require the issuance of referrals for specialist care,
the primary care provider (PCP) 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
PCP 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.
Referral requirements
In addition to the requirement that PCPs 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 PCP. After an initial consultation,
additional referrals from the PCP 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 PCP
• Will need an extension beyond the referral expiration
date
We require specialists to communicate with the referring
provider in a timely fashion. After receiving the
consultation report from the specialist, the PCP can
consider the appropriate course of treatment (for
example, referrals for additional services and/or
follow-up care, if needed). Referrals do not permit
specialists to refer members to another specialist for
care. If this is necessary, patients must get a referral from
their PCP 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.
When referrals are not required
Some plans do not require the issuance of a referral. In
those plans, a patient may self-refer to either
participating or nonparticipating providers. The patient is
responsible for paying any applicable copayment,
deductible and/or coinsurance for self-referred benefits.
See the “Utilization Management” section on page 34
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
provider.
No plans require a referral for emergency services.
Notice and termination
You must notify Aetna in writing any time you obtain a
financial ownership interest in a provider that may be
utilized for referrals or treatment of Aetna members. This
notification must be completed within thirty (30) days of
the acquisition of the ownership interest and include the
name, address, and TIN of the provider.
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 a nonparticipating
provider after notice and informed consent of the
patient has been documented in writing.
* FOR REFERRALS IN TEXAS: Referrals in Texas are only valid for thirty (30) calendar days. After that time frame, the
provider must provide a new referral.
Member’s consent for nonparticipating
providers’ referrals
In the event you refer a member to a nonparticipating
provider, in accordance with Company policies and the
member’s plan, you must acquire the member’s written
consent. This consent must be obtained at the time the
referral is made and, unless an emergency exists, be
done in advance of the date of scheduled procedure, or
appointment with the nonparticipating provider. The
obligation to obtain this consent cannot be delegated to
the nonparticipating provider or facility.
Note: For plans that are subject to state laws of
Maryland, Virginia and the District of Columbia, the
member should be directed to their PCP for referrals for
laboratory and radiology services.
The consent should state that the member has been
advised of the following:
• If the hospital, facility, or provider is not a participating
provider
• If the member’s plan may provide reduced benefits
• If the nonparticipating provider will not be restricted to
seeking payment only from Aetna®
• If the provider may bill the member for amounts other
than deductibles, copayments, coinsurance and
medical services not covered under the plan
• Any affiliation or financial ownership interest you may
have in or with the nonparticipating provider
• Such consent must include an approximate amount
that will be charged by the nonparticipating provider
and advise the patient of his or her personal financial
responsibility.
Referral processes
Electronic referrals should be issued for all plans that
require referrals (see the Aetna Benefits Products
Booklet). For information on submitting electronic
referrals, see the “Electronic Solutions” section of this
Provider Manual. 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. (Providers and other
health care professionals in upstate New York should
continue to work with Aetna and/or their respective IPA in
their usual manner.)
Note: Providers who provide telehealth services on a
hybrid or virtual-only basis should refer to the
Participation Criteria for additional referral criteria.
Utilization management
Overview
Our Care Management model integrates available
programs and services. This includes utilization
management, case management, disease management,
and specialty programs 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 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 require 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 when applicable.
*FOR COVERAGE NOTE: 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
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• 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 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 so, we expect you
to work with us to transfer the member’s care to a
specialty program provider.
How to contact us about utilization
management issues
• You may 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.
• Our staff, including medical directors, are also available
after hours, on weekends and on company holidays to
assist with provider and member inquires regarding
utilization management issues via the toll-free 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:
• State-mandated use of particular criteria and guidelines
• MCGTM guidelines (Seattle, WA: MCG Health, LLC)
• Level of Care for Alcohol and Drug Treatment Referral
(LOCADTR) (NY)
• Clinical Policy Bulletins (CPBs) or Pharmacy Clinical
Criteria — Clinical Policy Bulletins (based on medical
and pharmacy Clinical Policy Bulletins (CPBs)
• 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
• Level of Care Utilization System (LOCUS) and Child and
Adolescent Level of Care/Service Intensity Utilization
System and Child and Adolescent Service Intensity
Instrument (CALOCUS-CASII)
• 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.
Note: 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 noon CT on weekends and legal holidays.
(For all other times, phone recording systems are used.)
36
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) 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
two business days
Beginning December 1, 2023, we need notice of all
inpatient admissions, including those through the
emergency department, within two business days 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 at the time of your notification. 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. Certain
admission exclusions may apply. The timely Notification
Policy and all Aetna payment policies can be found on
Availity; or you can call the Provider Contact Center. To
sign up for Availity, follow instructions on Aetna.com.
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
Women's Health 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 may also submit unsolicited medical
records using one of our participating vendors through the
electronic attachments transaction (X12N 275). View our list
of participating precertification vendors that accept
unsolicited attachments for precertification at
Aetna.com/provider/vendor.
*FOR PRECERTIFICATIION REQUIREMENT: This may be the member’s responsibility in certain plan types that offer
out-of-network benefits. Per Medicare laws, rules and regulations, there is no penalty to Medicare Advantage plan
members if they do not get precertification.
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You can find more information about our
precertification policy on our website.
On our website, you can also access an updated
list of services requiring precertification.
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.
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 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 DISEASE MANAGEMENT PROGRAM: Aetna Medicare members have access to this 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 more information or to refer
members, call the Member Services number on the Aetna member ID card.
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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.
Aetna Women's Health Program
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.
Aetna Institutes® Gene-based, Cellular and Other
Innovative Therapies (GCIT®) Designated Networks
The Aetna Institutes GCIT Designated Networks program
helps patients who have been diagnosed with certain
genetic conditions that can be treated with the use of
innovative GCIT products that have been approved by
the U.S. Food and Drug Administration (FDA).
To be part of the GCIT-Designated Network, a health care
facility must meet specific GCIT program criteria.
Behavioral health
On Aetna.com, check out information on the “Behavioral
Health” page. There, you’ll find:
• Archived issues of our Office Links Updates
newsletter with information for participating behavioral
health professionals
• Aetna Behavioral Health Programs overview
• Utilization Management and how we
determine coverage
39
Behavioral Health Accessibility standards and
participation criteria
Providers are required to comply with Aetna participation
requirements, which are available in our participation
criteria.
We have standards for member access to behavioral
health services, which are listed in our participation
criteria, along with other PCP criteria.
Behavioral Health Screening Programs
Complex Case Management
All members referred to the Complex Case Management
program are screened for the presence of co-occurring
mental health and substance use disorders. This is
applicable for both Commercial and Medicare lines of
business. The Complex Case Management program
utilizes recognized screening instruments to support
members in the identification and diagnosis of
co-occurring mental health and substance use
disorders. These instruments are tools to be used to
inform members and care managers in developing the
care plan goals and coordinating care or making referrals
to the most appropriate providers.
These members will receive:
• An initial screening for coexisting mental health and
substance use disorders using evidenced-based
screening tools
• A individualized care plan (if the screening shows the
co-existing conditions)
• A behavioral health care manager who, as a part of the
care team, will help maintain continuity of care
The 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:
• Recommended tools to screen for depression as well
as monitor response to treatment
• Reimbursement for depression screening and follow-up
monitoring
To participate, you just need to be a participating primary
care provider, use a recommended screening tool to
screen your patients and submit claims with the following
billing combination (select the most appropriate): CPT
code(s) “96127” (brief emotional/behavioral assessment),
“96160” (patient-focused health risk assessment) or
“96161” (caregiver-focused health risk assessment) in
conjunction with diagnosis code(s) “Z13.31” (screening for
depression), “Z13.32” (screening for maternal
depression), or “Z13.39” (screening for other mental/
behavioral health disorders). To learn more, visit the
Aetna Depression in Primary Care Program page.
40
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.
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 use 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.
The Aetna Opioid Overdose Risk Screening Program
Our behavioral health clinicians screen members to
identify those who are at risk for an opioid overdose. Any
member with a diagnosis of opioid dependence may be
at risk.
You can help rescue patients
Naloxone (also referred to with the brand version name
Narcan®) reverses the effects of an opioid overdose.
Giving naloxone kits to laypeople reduces overdose
deaths, and it's safe and cost effective.* You can also tell
patients and their families and support networks about
signs of overdose and train them on how to administer
the medication.
For fully insured commercial plans, coverage of naloxone
varies by the group plan and each member's specific
benefits. When it is covered, we waive copays for the
naloxone rescue medication. For more information on
coverage, call the number on the member's ID card.
Resources for you and your patients
• Aetna opioid resources
• CVS Health opioid response
• U.S. Department of Health and Human Services:
Naloxone: The Opioid Reversal Drug that Saves
Lives (PDF)
• U.S. Substance Use and Mental Health Services
Administration (SAMHSA) Opioid Overdose
Prevention Toolkit (PDF)
D-SNPs screening for coexisting behavioral health
and substance use disorders
Do you have Medicare-Medicaid Dual-Eligible Special
Needs Program (D-SNP) members? Our behavioral
health clinical team works with D-SNP members to
identify those who may have a behavioral health and/or
substance use disorder diagnosis.
These members will receive:
• An initial screening for coexisting mental health and
substance use disorders using evidenced-based
screening tools
• An individualized care plan (if the screening shows the
coexisting conditions)
• A behavioral health care manager who, as a part of the
care team, will help maintain continuity of care
How to make a referral
Help make sure these members get the quality care they
need. Refer them to Aetna D-SNP.
Resources
• Aetna emotional well-being resources
• U.S. Centers for Medicare & Medicaid Services
Roadmap to Behavioral Health U.S.
• Substance Use and Mental Health
Services Administration
*FOR NALOXONE SOURCE: Wheeler E, Jones S, Gilbert MK, et al. Opioid overdose prevention programs providing
naloxone to laypersons — United States, 2014. Centers for Disease Control and Prevention (CDC) Morbidity and
Mortality Weekly Report (MMWR). June 19, 2015;64(23);631 to 635. Accessed February 26, 2021.
41
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.
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 Prescription Drug Plans
You can find the Medicare prescription drug formularies
at the following links:
• Individual MAPD plan and PDP members
• Group MAPD 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.
How your patients can learn more
To learn more, encourage members to visit our
Aetna member website. Once logged in, instruct
them to select Pharmacy at the top of the page.
42
Treating complex diseases and chronic conditions
Some specialty medications and infusion therapies are
available only through limited distribution networks.
CVS Specialty® works hard to monitor the FDA pipeline.
It is part of our effort to get access to new specialty
therapies quickly.
If CVS Specialty gets a prescription order for a therapy we
don’t have access to, our team responds without delay.
We return the referral/prescription back to the sending
source advising them who can service (if known).
Ordering through CVS Specialty is easy
• E-prescribe: NCPDP ID# 1466033
• Fax: 1-800-323-2445
• Phone: 1-800-237-2767 (TTY: 711)
Physicians can enroll for ePrescribe by visiting the CVS
Specialty website. Prefer to fax? Print and complete an
enrollment form.
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
The CVS Health® Payer Solutions 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
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).
43
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 Precertification Unit. Refer to the
Medical Exception and Precertification information on
how to access this unit.
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.
44
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 Precertification Unit.
To contact us, see the options below.
Phone Fax Online
Commercial 1-855-240-0535 (TTY: 711) 1-877-269-9 916 —
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 the Novologix®
platform.
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 the Novologix®
platform.
45
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 require 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.
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
• E-prescribing
• 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
• The city of Tampa, Florida
• The cities of Cleveland and Columbus, Ohio
46
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 a provider’s own year-over-year performance
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. 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.
47
Clinical practice guidelines
• American College of Cardiology Guidelines
• American Diabetes Association (ADA): Standards
of Medical Care in Diabetes
• Center for Disease Control and Prevention Opioid
Prescribing Guideline
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 Society of Addiction Medicine (ASAM)
Clinical Practice Guideline on Alcohol Withdrawal
Management (2020)
• American Society of Addiction Medicine (ASAM)
National Practice Guideline for the Treatment of
Opioid Use Disorder (2020)
• VA/DoD Clinical Practice Guideline for the
Management of Major Depressive Disorder (MDD)
(2022)
• American Psychiatric Association (APA) Practice
Guideline for the Treatment of Patients with
Schizophrenia, Third Edition (2022)
Preventive services guidelines
• Centers for Disease Control and Prevention
Immunization Schedules
• U.S. Preventive Services Task Force
• Health Resources and Services Administration
(HRSA) Women’s Preventive Services Guidelines
Case management
According to the Case Management Society of America’s
website, "Case management serves as a means for
achieving client wellness and autonomy through
advocacy, communication, education, identification of
service resources and service facilitation. The case
manager helps identify appropriate providers and
facilities throughout the continuum of services, while
ensuring that available resources are being used in a
timely and cost-effective manner in order to obtain
optimum value for both the client and the reimbursement
source. Case management services are best offered in a
climate that allows direct communication between the
case manager, the client, and appropriate service
personnel, in order to optimize the outcome for all
concerned."* Case management is a standard component
of most Aetna® medical plans.
The basis 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, standard and low-risk 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 determine the level of case management
needed and the member or caregiver agrees, we make
an individualized plan that's specific to the member's
situation and needs.
Clinical care management staff, in coordination with
the attending practitioner, member, or the member's
representative, develop an individualized case
management plan based upon an assessment of the
member’s situation and needs. The case management
plan includes documentation of prioritized goals, which
are specific, measurable, and time-bound, and reflective
of issues identified in the member assessment, and the
supporting rationale for each selected goal.
Clinical care management staff review, monitor and
evaluate progress against case management plans and
goals, and modify as needed 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.
*FOR CASE MANAGEMENT QUOTE SOURCE: Case Management Society of America. What is a Case Manager? 2022.
Accessed January 24, 2023.
48
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.* 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.*
To this end, we strongly encourage you to send
progress notes and discharge summaries to your
patients’ other treating practitioners. Forms are
available on our public website at Aetna.com and
include 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.
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)
• Is not included within a plan sponsor-specific network
Additionally, the treating provider must be an individual
practitioner (for example, a specialist, physical therapist,
or 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.
*FOR COMPLIANCE AND OUTCOME SOURCE: Scotten M, Manos EL, Malicoat A, et al. Minding the gap:
interprofessional communication during inpatient and post discharge chasm care. Patient Education and
Counseling, an official journal of EACH, the International Association for Communication in Health Care, and the
Academy of Communication in Healthcare. July 2015;98(7):895 to 900. doi: 10.1016/j.pec.2015.03.009. Epub 2015 Mar
17. PMID: 25862470. Accessed April 8, 2021.
*FOR QUALITY OF COMMUNICATION SOURCE: Mohr DC, Benzer JK, Vimalananda VG, et al. Organizational
coordination and patient experiences of specialty care integration. The Journal of General Internal Medicine, the
official journal of the Society of General Internal Medicine. May 2019;34(Suppl 1):30 to 36. doi: 10.1007/s11606-019-
04973-0. PMID: 31098971; PMCID: PMC6542960. Accessed April 8, 2021.
49
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)
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: State-specific laws do not apply to Medicare
Advantage appeals. Commercial plans may vary
based on state-specific requirements.
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.
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 for further information.
*FOR ACTIVE COURSE OF TREATMENT DEFINITION: State variations from our definition of "active course of treatment"
exist. In those cases, use the state definition instead of our definition.
*FOR DISPUTE AND APPEAL POLICY: 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 51 of this manual, for further information.
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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 renal dialysis — 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 (MAPD).
We offer both individual and employer group-sponsored
MA products. The Aetna Medicare Advantage HMO
plans are available in select counties and states
throughout the country. Aetna Medicare Advantage
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.
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
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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, call our Provider Contact
Center at 1-800-624-0756 (TTY: 711).
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.
Effective management of chronic disease can achieve
positive outcomes. Examples of documented outcomes
include slowing disease progression, preventing
complications and development of comorbidities,
reducing preventable emergency room (ER) encounters
and inpatient stays, improving the member's quality of
life, and providing cost savings for the member.
Medicare prescription drug plan
We administer a stand-alone prescription drug plan
(PDP) portfolio of products referred to as SilverScript.
There are several different national PDP plan options
available to individuals. In select service areas, Medicare
prescription drug benefits are also offered to individuals
for their retirees through our MA plans that include
Medicare prescription drug coverage (MAPD) plans.
In addition, employer groups nationwide may select
Medicare prescription drug coverage for their retirees
through Aetna Medicare Rx® offered by SilverScript for
PDP or Aetna Medicare for MAPD.
MAPD plans and PDPs must meet applicable benefits
requirements under the Medicare Part D program and,
as of 2024, at a minimum, these plans must contain the
following provisions.
• Deductible: Not to exceed $545 for 2024.
• Coverage gap: Once a member reaches $5,030 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 $8,000. Most individual and group PDP and MAPD
plans provide supplemental gap coverage.
• Insulin Cost Share: Beginning January 1, 2023, people
with Medicare drug coverage who take insulin will see
their out-of-pocket costs capped at $35 for a month’s
supply of each covered insulin product. Also, a Part D
deductible won’t be applied to covered insulin products.
• Catastrophic coverage level: For 2024, once a
member reaches $8,000 in TrOOP costs for covered
Part D drugs, the member’s cost share will be $0 for all
covered Part D 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 Drug
List”) differ from the formularies applicable to Aetna
commercial pharmacy plans.
- Go to AetnaMedicare.com/formulary to see a
list of Medicare prescription drug formularies.
- Group MAPD Plan and PDP members: visit our retiree
plans website at AetnaRetireePlans.com to see a list
of Medicare prescription drug formularies.
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Note: All formularies applicable to MAPD 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 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.
See our transition-of-coverage policy to view
the transition rules for our Medicare prescription
drug process.
Additional prescription drug plan
information
Beginning in 2023, members will not pay more than $35
for a one-month supply of each insulin product covered
by our plan, no matter what cost-sharing tier it is on and
even if the member has a deductible which has not yet
been met. In addition, our plan covers most Part D
vaccines at no cost to the member, even if the member
has a deductible which has not yet been met.
• Days supply: Generally, a 1-month prescription may be
filled for up to a 30-day supply. Members may obtain
extended day supplies of maintenance medications
from either a participating retail pharmacy or through a
participating mail-order vendor. Individual MAPD
members may get up to a 100-day supply of most
maintenance medications; Group MAPD and PDP
members may get up to a 90-day supply.
• Mail-order drug option: Individual MAPD members
may get up to a 100-day supply. All others may get up
to a 90-day supply.
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.” CVS Specialty® pharmacy can support
Medicare members in need of specialty medications and
support as well as other in network pharmacies based
upon the member's benefit. Search tools for the
pharmacy network are available on the member's benefit
page to assist in selecting a retail, mail or specialty
pharmacy for prescription access.
53
In 2014, CMS instituted a feature that allows PDP and
MAPD 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.
Preferred pharmacies
Most of our plans have a pharmacy network which
includes access to preferred pharmacies.
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. Or go to AetnaMedicare.com/
findpharmacy to search online.
Note: The previous description is not applicable to
members who qualify for Low-Income Subsidy assistance.
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 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 a CMS-compendia-recognized
resource such as:
• 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 non D-covered
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 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 MAPD 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.
54
• 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.
• 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.
Our objective is to give members the comfort of knowing
that 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
procedure or treatment
• Any reasonable alternatives to such recommended
treatment
Demographic data quarterly attestation
We require Aetna-contracted Medicare Advantage
providers to validate their demographic information
quarterly as noted in our provider agreement and/or
provider newsletters. Availity® will send a notification
each quarter for your review and attestation. As an
Aetna Medicare Advantage provider, you are obligated
to comply with this validation.
If you move your office, or change other demographic
information, such as your email address or phone
number, go to the Provider Data Maintenance function
on Availity to 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 complete the validation and
attestation requests from Availity within the allotted time
frame. To do so, login to the provider portal and complete
the attestation of your demographic information. We take
this requirement very seriously and will act against
providers who refuse to cooperate. Ultimately, this action
can include termination of your participation in our Aetna
Medicare Advantage networks.
The U.S. 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
CMS in reminding providers to review, update, and
certify that their data is current in the National Plan &
Provider Enumeration System (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.
55
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
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
• Members can be granted 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 maintenance and
access to records obligations.
These 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 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
to the Member Rights and Responsibilities policy for
more information on advance directives.
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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.
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Medicare prescription drug plan (PDP and MAPD)
coverage determinations and exceptions process
Coverage determinations
Medicare beneficiaries enrolled in PDPs and MAPDs
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 MAPD) and Medicare
PDP member grievance and appeal rights
Medicare beneficiaries enrolled in MA, MAPD, 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 MAPD 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. MAPD 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
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member appeals and grievances. If necessary,
contracted providers should:
• Instruct the member to contact us for their MA plan
appeal rights
• 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, MAPD, 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 MAPD or PDP
members)
• Aetna Medicare Advantage: Appeals and
Grievances (medical requests for MA or MAPD
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 and 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 33 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.
Beginning, January 1, 2023, Part D-covered adult
vaccines recommended by the Advisory Committee on
Immunization Practices (ACIP), including the shingles
and Tetanus-Diphtheria-Whooping Cough vaccines, will
be available with no deductible and no cost-sharing to
people with Medicare prescription drug coverage.
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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 members with a 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.
For more information, visit our
Health Care Professionals Medicare page.
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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, MAPD, and/or PDP
• 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/
health-care-professionals/medicare.html 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.
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.
Report concerns or questions
If you identify noncompliance or fraud, waste and abuse,
you must 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,
call our Provider Contact Center.
Special Needs Plans (SNPs) Model of Care
A Dual Eligible Special Needs Plan (D-SNP) including
Highly Integrated Dual Special Needs Plan (HIDE), and
Fully Integrated Special Needs Plan (FIDE), are types of
Medicare Advantage plans for delivering coordinated
care and care management, as well as provide benefits
to Medicare-qualified members who may also receive
full or partial Medicaid benefits and/or assistance with
Medicare premiums or Parts A & B cost-sharing. These
Special Needs Plans (SNPs) include a Model of Care
(MOC) inclusive of a coordinated care/care management
program offered to all special needs members. The
Centers for Medicare & Medicaid Services (CMS)
requires that all contracted medical providers and staff
receive basic training about the Special Needs Plans
(SNPs) MOC. This training and completion of an
attestation are required for new providers and must be
completed yearly. Additional Medicare Advantage SNP
products requiring the MOC attestation include
Institutional Special Need Plan (ISNP) and Chronic
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Special Needs Plans (CSNP). Go to Aetna.com/
health-care-professionals/medicare.html to find the
SNP MOC, Provider and Delegate Frequently asked
questions, and DSNP/FIDE Attestations. Go to the Office
Manual Supplement (all states) (PDF) to find additional
state specific SNP MOC guidance.
The Patient Protection and Affordable Care Act
(PPACA), implemented in 2010
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. Sections of the ACA 1557
portion were repealed in the summer of 2020 with an
effective date of 8/18/20. Aetna expects providers to
comply with ACA Section 1557. Sections of the ACA 1557
portion were repealed in the summer of 2020, with an
effective date of August 8, 2020.
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.
• Ensure the ability to assist members in a variety of
languages, per federal law requirements.
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.
Auxiliary support and service options
The regulations include a long, but non-exhaustive 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
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• 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.
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 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.
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-only 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
2021, 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)
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)
*Twelve months for members enrolled in a stand-alone Medicare prescription drug plan (PDP).
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Louisiana (LA)
Maine (ME)
Massachusetts (MA)
Michigan (MI)
Washington (WA)
Wisconsin (WI)
Wyoming (WY)
• 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 their PCP to a PCP located
in another Aetna Medicare plan service area.
• If a plan requires that a PCP selection be recorded by
Aetna, 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, MAPD, and
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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.
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.
Care outside of the United States
If the member sees an out-of-network provider for
urgent/emergency care outside of the United States and
he/she has made payment to the provider, the member
should submit their claims to Aetna® along with
documentation of any payments made to the provider.
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). CMS may adjust payments
to the MAO based on the outcome of the medical
record review.
65
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.
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
66
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.
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)
Medicare marketing guidelines contain restrictions on
communications and marketing materials for MA plans
and providers. We summarize here some of the key
requirements, but we encourage providers to review
these regulations and guidelines available on the CMS
website. Per Medicare regulations, to qualify as a
“marketing material,” material must meet content and
intent requirements set forth in CMS guidance. Materials
will meet the intent requirement if they are intended to (i)
draw a beneficiary's attention to a plan or plans, (ii)
influence a beneficiary's decision-making process when
making a plan selection, or (iii) influence a beneficiary's
decision to stay enrolled in a plan (retention-based
marketing). To meet the content requirement, materials
must include content regarding (i) the plan’s benefits,
benefits structure, premiums, or cost sharing; (ii)
measuring or ranking standards (for example, Star
Ratings or plan comparisons), or (iii) rewards and
incentives as defined under 42 CFR § 422.134(a) (for MA
and section 1876 cost plans only). Marketing or sales
activities and materials are not permitted in areas where
care is being administered, including exam rooms,
hospital patient rooms, treatment areas, or pharmacy
counter areas.
Permissible activities
Provider-initiated activities are activities conducted by a
provider at the request of the patient, or as a matter of a
course of treatment, and occur when meeting with the
patient as part of the professional relationship between
the provider and patient. Permissible activities include:
1. Distributing unaltered, printed materials created by
CMS, such as reports from Medicare Plan Finder, the
“Medicare & You” handbook, or “Medicare Options
Compare” (from Medicare.gov), including in areas
where care is delivered.
2.Providing the names of MA organizations with which
they contract or participate or both.
3.Answering questions or discussing the merits of a MA
plan or plans, including cost sharing and benefit
information, including in areas where care is delivered.
4.Referring patients to other sources of information,
such as State Health Insurance Assistance Program
(SHIP) representatives, plan marketing
representatives, State Medicaid Office, local Social
Security Offices, CMS' website at Medicare.gov, or
1-800-MEDICARE.
5.Referring patients to MA plan marketing materials
available in common areas
6.Providing information and assistance in applying for
the Low-Income Subsidy (LIS).
67 67
7. Announcing new or continuing affiliations with MA
organizations, once a contractual agreement is
signed. Announcements may be made through any
means of distribution.
What contracted providers may do
• Make available, distribute, and display communications
materials, including in areas where care is being
delivered.
• Provide or make available marketing materials and
enrollment forms in common areas.
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.
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.
Rights
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.
• Get information in a way that works for them. Our plan
includes:
- Free language interpreter services available to answer
questions from non-English-speaking members.
- Information in braille, large print, and in other
accessible formats.
- Information that is 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.
68
• 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.
• Call Member Services if they have a disability and
need help in order to access to care.
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.
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
69
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.
Responsibilities
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.
Rights
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. The information we
provide about our benefits must be accessible and
appropriate for people who are eligible for Medicare
because of a disability. If they need it, we can also give
members information in Braille, in large print, or other
alternate formats.
• 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)
70
• 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
• 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.
Responsibilities
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.
71
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.
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. 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
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)
72
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.”
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Behavioral Health
Our guiding principles
Our behavioral health programs support our belief in the
following:
• Enhancing our members’ — your patients’ —
clinical experiences
• Adhering to the importance of the mind-body principle
and connection
• Providing a treatment approach that is evidence-based,
goal-directed, and consistent with accepted standards
of care, all Aetna Clinical Policy Bulletins, and Aetna
clinical practice guidelines
• Providing treatment that is medically necessary
• Educating members about the risks and benefits of
available treatment options
• Developing a strong relationship with you, informing you
about resources, and concentrating on continuity of
care among all, for the benefit of you and your patients
• Integrating behavioral health care across our product
spectrum
How to reach us
Our medical directors and staff are available to speak
with you about utilization management issues. Staff is
available, during and after business hours, via toll-free
telephone numbers. Behavioral health medical directors
make all final coverage* denial determinations involving
clinical issues.
If a treating provider doesn’t agree with a decision about
coverage or wants to discuss an individual member’s
case, Aetna Behavioral Health staff are available 24 hours
a day, 7 days a week. Behavioral health care providers
can contact staff during normal business hours (8 AM to
5 PM, Monday through Friday)* by calling the toll-free
precertification number on the member’s ID card. When
only a Member Services number is shown on the card,
you’ll be directed to the Precertification unit through
either a phone prompt or a Member Services
representative.
On weekends, company holidays, and after normal
business hours, members and providers can use these
same toll-free phone numbers to contact our staff. Our
staff identify themselves by name, title and organization
when they initiate or return calls about utilization
management issues. We also offer TDD/TTY services for
deaf, hard-of-hearing, or speech-impaired members,
and language assistance for members to discuss these
issues.
* FOR COVERAGE DETERMINATIONS: For these purposes, “coverage” means either the determination of (i) whether or
not the particular service or treatment is a covered benefit under the terms of the particular member’s benefits plan, or
(ii) where a physician or health care professional is required to comply with the Aetna patient management programs,
whether or not the particular service or treatment is payable under the terms of the provider agreement.
* FOR CONTACT HOURS: All continental U.S. time zones; hours of operation may differ based on state regulations. In
Texas: 6 AM to 6 PM CT (Monday through Friday) and 9 AM to noon CT on weekends and legal holidays. Phone
recording systems are in use during all other times.
74
Our programs
Behavioral Health Condition Management program
We offer a case management program that supports
patients’ medical and psychological needs. Our focus is
on helping our members make the best use of their
benefits by coordinating behavioral health and wellness
services. To support the efforts of clinicians, we also
closely follow patient progress and treatment
recommendation adherence and share it with you.
Through this program, we:
• Work with your practice and other health care
professionals on patient progress
• Evaluate patient needs to promote full use of covered
services and benefits in support of your treatment plan
• Provide educational materials and decision-support
tools, both online and via mail, so patients better
understand their illness
• Use case management by phone to support patient
adherence to your treatment plan
This program provides additional care options for your
eligible Aetna® patients.
Who may benefit from our Behavioral Health
Member Support program
• Aetna members (children, adolescents and adults):
- With co-occurring medical and behavioral health
conditions
- With complex behavioral health conditions who have
had inpatient readmissions, extended hospitalization
stays, or suicide attempts resulting in medical
admissions
• Aetna members ages 14 and older:
- Who have symptoms of major depression, dysthymia,
depression not otherwise specified, or bipolar
depression
- Who are diagnosed with anxiety disorders, such as
generalized anxiety, panic disorder, or post-traumatic
stress syndrome
• Aetna members ages 18 and older who have a
substance use disorder
Members who complete this program show significant
symptom relief and improvement in overall health.
To learn more about the Aetna Behavioral Health
Member Support program, call us at 1-800-424-4660
(TTY: 711).
The minimum criteria to become a credentialed Aetna®
behavioral health care professional are:
• Graduation from an accredited professional school
applicable to the applicant’s degree, discipline and
licensure
• For physicians, completion of residency training in
psychiatry and board certification, unless the physician
meets the conditions delineated in our board
certification exception policy; a medical director reviews
exceptions to the board certification requirement
• Malpractice insurance in amounts specified in the
Aetna agreement
• Availability for emergencies by mobile device or other
established procedures that we deem acceptable
• Submission of an application containing all applicable
attestations, necessary documentation and signatures
• If applicant is a physician addictionologist, certification
by the American Society of Addiction Medicine (ASAM)
• Current, unrestricted license
• The absence of current debarment or suspension from
state or federal programs
75
Clinical delivery
Access to care
Members may access behavioral health care in
three ways:
1. Through direct access to the behavioral
health provider
2. Through a recommendation from the primary care
physician or other treatment provider
3. Through a referral from an employee assistance or
student assistance program provider
For a list of services that require precertification and
concurrent review, go to AetnaElectronicPrecert.com
and click “Check our precertification lists.” To request
precertification, use our provider portal at Availity.com
or any other website that allows you to send
precertification requests electronically. (You can register
at Availity.com for our provider portal via Availity®.) You
may also use the toll-free behavioral health telephone
number on the member’s ID card. For Open Choice® and
Traditional Choice® plan members, use the toll-free
Member Services telephone number on the member’s ID
card. These numbers are accessible 24 hours a day,
7days a week. A screening process to determine the
urgency of the need for treatment may occur at the time
of the call.
Authorization and precertification process
Authorization/precertification is the process of
determining the eligibility for coverage of the proposed
level of care and place of service.* To ensure Aetna®
members receive the highest quality of care, a
comprehensive diagnostic evaluation prior to the
initiation of treatment is expected. Diagnoses submitted
on claims must be current and consistent with the most
recent Diagnostic and Statistical Manual of Mental
Disorders (DSM) criteria. Collecting complete and
accurate clinical data is critical to successfully
completing the authorization process. Treatment
approach is expected to be evidence based, goal
directed, and consistent with accepted standards of
care, Aetna Clinical Policy Bulletins and Aetna clinical
practice guidelines.
It is also expected that treatment provided is medically
necessary: “Medically necessary services are those
health care services that a practitioner, exercising
prudent clinical judgment, would provide to a patient for
the purpose of preventing, evaluating, diagnosing or
treating an illness, injury, disease or its symptoms, and
that are (a) in accordance with generally accepted
standards of medical practice; (b) clinically appropriate,
in terms of type, frequency, extent, site and duration, and
considered effective for the patient’s illness, injury or
disease; (c) not primarily for the convenience of the
patient, physician or other health care provider; and (d)
not more costly than an alternative service or sequence
of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or
treatment of that patient’s illness, injury or disease. For
these purposes, ‘generally accepted standards of care’
means standards that are based on credible scientific
evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community,
or otherwise consistent with physician specialty society
recommendations and the views of physicians practicing
in relevant clinical areas and any other relevant factors.”
Some employers have specific preauthorization
requirements for their employees, so always check
with our Provider Service Center at 1-800-624-0756
(TTY: 711) for HMO and Medicare Advantage plans and
1-888-MDAetna (1-888-632-3862) (TTY: 711) for
all other plans.
• All inpatient behavioral health services must be
precertified and are managed through a concurrent or
retrospective review process.
Intermediate levels of care, such as residential treatment,
and partial hospitalization also require precertification. For
more information, go to AetnaElectronicPrecert.com
and click “Check our precertification lists.”
*FOR PRECERTIFICATION DEFINITION: Precertification is the process of collecting information before inpatient admissions
and selected ambulatory procedures and services for the purpose of (1) receiving notification of a planned service or
supply, or (2) making a coverage determination. It doesn’t mean precertification as defined by Texas law as a reliable
representation of payment.
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Exceptions:
This policy applies to all Aetna® plans with the exception
of behavioral health benefits that we administer but don’t
manage and self-funded plans with plan sponsors that
have expressly purchased precertification requirements.
In addition to reviewing clinical information to determine
coverage, our utilization management clinician will
discuss treatment alternatives, the appropriate level of
care and explore discharge planning opportunities. If
Aetna case management is involved, we will request that
the member’s family, physician(s), and other health care
professionals be involved in the treatment plan and
activities. We recommend that you discuss the available
benefits for outpatient care with your patient, so that
treatment can be planned accordingly.
You can submit a precertification request in one of
three ways:
1. Through Availity.com (our provider portal)
2. Through one of our vendors — go to
Aetna.com/provider/vendor to see our list
3. By calling our Provider Service Center at
1-800-624-0756 (TTY: 711)
Electronic claims.
Note:
Stepping down to a less restrictive level of care within the
same facility (for example, a step down from inpatient
detoxification to inpatient rehabilitation), even within the
same unit of the same facility, requires precertification.
At times, a member may seek treatment outside of our
network (for example, a nonparticipating referral for
routine outpatient behavioral health services). This is a
written or verbal request that we review. Reasons that a
nonparticipating referral may be approved include:
• When a specific health care professional preferred by
the member isn’t available in network (and the
member’s plan provides coverage for
out-of-network services)
• When the member is continuing, or returning to,
treatment with a nonparticipating health care
professional, in certain circumstances
• When the primary care practitioner identifies a local or
known nonparticipating health care professional with
expertise in the treatment of the member’s condition
(and the member’s plan provides coverage for
out-of-network services)
More about precertification of behavioral
health services
It’s important to note that outpatient care that isn’t
consistent with evidence-based, goal-directed practices,
Aetna Clinical Policy Bulletins and Aetna clinical practice
guidelines may be subject to quality-of-care and
utilization reviews.
Also note that outpatient care inconsistent with
such a treatment approach may be subject to a
concurrent review.
It’s expected that facility diagnostic evaluations assess
for either comorbid chemical dependency or comorbid
psychiatric conditions that could be impacting
current presentation.
Go to Aetna.com for more information on
services requiring precertification and
electronic precertification.
A complete list of behavioral health services requiring
authorization and precertification is available at
Aetna.com in the “For Providers” section. Some
employers have specific precertification requirements for
their employees. To verify outpatient precertification
requirements for a specific member’s plan, contact our
Provider Service Center.
Precertification for ABA
Applied behavior analysis (ABA) services require
precertification. To get ABA services precertified, call the
number on the member’s Aetna® ID card and speak to a
Member Services representative.
See our medical necessity guidelines for ABA. We’ve
used the American Medical Association Category I CPT
codes (97151–97158) for Adaptive Behavior Treatment as
of January 1, 2019, and Category III CPT codes (0362T
and 0373T).
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Coverage determinations and utilization
management (UM)
We use evidence-based clinical guidelines from
nationally recognized authorities to make UM decisions.
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 consistently
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, Centers
for Medicare and Medicaid Services (CMS) and National
Committee for Quality Assurance (NCQA) requirements.
If we deny a request for coverage, the member (or a
physician acting on the member’s behalf) may appeal
this decision through the complaint and appeal process.
Depending on the specific circumstances, the appeal
may be made to a government agency, the plan sponsor,
or an external utilization review organization that uses
independent physician reviewers, as applicable.
We don’t reward physicians or other individuals who
conduct utilization reviews in order to issue denials of
coverage or create barriers to care or service. Financial
incentives for utilization management decision makers
don’t 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 don’t encourage utilization-related
decisions that result in underutilization.
Learn more
Staff is available 24 hours a day for specific utilization
management issues. Contact us by:
• Visiting our website
• Calling us at 1-800-624-0756 (TTY: 711)
• Calling Utilization Management staff using the
Member Services number on the member’s ID card
How we determine coverage
Our medical directors make all coverage decisions that
involve clinical issues. Only licensed medical directors,
psychiatrists/psychologists and pharmacists make denial
decisions for reasons related to medical necessity.
(Licensed 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 a
pharmacist who is licensed to practice in that state.
Patient Management staff use evidenced-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.
1. Level of Care Utilization System:*
The Level of Care Utilization System for Psychiatric and
Addiction Services, or LOCUS, is a nationally
recognized level of care tool used to help determine
the resource intensity needs of individuals who receive
adult mental health services. It is used for patients
18years and older who are in need of placement in
specialized psychiatric or mental health facilities or
units. This person-centered approach aims to find the
best fit between individual needs and behavioral health
services. For more information about LOCUS, visit the
American Association of Community Psychiatry (AACP)
website at CommunityPsychiatry.org.
The Child and Adolescent Level of Care/Service
Intensity Utilization System and Child and Adolescent
Service Intensity Instrument, or CALOCUS-CASII, are
nationally recognized tools used to determine the
appropriate level of care placement for a child or
adolescent. These tools are used for children and
adolescents from 6 to 17 years of age. For more
information about these tools, visit the American
Academy of Child and Adolescent Psychiatry (AACAP)
website at AACAP.org.
* FOR LEVEL OF CARE UTILIZATION SYSTEM: The LOCUS and CALOCUS/CASII are instruments that an Aetna clinician
uses to aid in the decision-making process. They help determine the level of care appropriate for effective treatment
for a mental health patient. “Aetna clinician” may mean a Licensed Behavioral Health Clinician or RN, an independent
physician reviewer working on our behalf or an Aetna medical director. LOCUS and CALOCUS/CASII guidelines don’t
constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members.
78
2. The ASAM Criteria: Treatment Criteria for
Addictive, Substance-Related and
Co-Occurring Conditions
This is a nationally recognized criteria set that helps
determine appropriate levels and types of care for
patients in need of evaluation and treatment for
chemical dependency and substance use conditions
and diagnoses. The third edition is compliant with the
DSM-5 and also applies for patients who are in need of
placement in specialized chemical dependency
detoxification or rehabilitation facilities or units.
Note:
We supply relevant pages of ASAM’s criteria upon
request. Please call us by any of the ways below to
submit a request.
• Provider Service Center: 1-800-624-0756
(TTY: 711)
• HMO and Aetna® Medicare Advantage plans:
1-800-624-0756 (TTY: 711)
• All other plans: 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
3. State-specific criteria
The Level of Care for Alcohol and Drug Treatment
Referral (LOCADTR) is used for chemical
dependency treatment that takes place in New York.
Our Applied Behavior Analysis (ABA) Medical
Necessity Guide
The ABA Medical Necessity Guide is a clinical
behavioral health patient-management instrument
used to guide and track treatment decisions for our
members in need of ABA. For practitioners treating
autism spectrum disorders using ABA, either national
certification is needed from the Behavior Analyst
Certification Board (BACB), or the practitioner must be
licensed as a behavior analyst in the state in which they
practice.
4. Aetna Clinical Policy Bulletins (CPBs)
These are based on evidence in peer-reviewed,
published medical literature; technology assessments
and structured evidence reviews; evidence-based
consensus statements; expert opinions of health care
providers; and evidence-based guidelines from
nationally recognized professional health care
organizations and government public health agencies.
CPBs are detailed technical documents that explain
how we make coverage decisions for members under
our health benefits plans. They spell out what medical,
dental, pharmacy and behavioral health technologies
and services may, or may not, be covered.
You can learn more about these guidelines on
our website.
Participating practitioners can ask for a hard copy of the
criteria we used to make a determination. Just call us at
1-888-632-3862 (TTY: 711).
Both new and revised CPB drafts undergo a
comprehensive review process that includes review by
our Clinical Policy Council. Our chief medical officer (or
designee) approves CPBs. The Aetna® Clinical Policy
Council evaluates the safety, effectiveness, and
appropriateness of medical technologies (that is, drugs,
devices, medical and surgical procedures used in
medical care, and the organizational and supportive
systems within which such care is provided) that are
covered under our medical plans, or that may be eligible
for coverage under our medical plans.
In making this determination, the Clinical Policy Council
reviews and evaluates evidence in the peer-reviewed,
published medical literature; information from the U.S.
Food and Drug Administration and other federal public
health agencies; evidence-based guidelines from
national medical professional organizations; and
evidence-based evaluations by consensus panels and
technology evaluation bodies.
The criteria noted above are only guidelines. Their use
doesn’t preclude the requirement that trained, licensed,
credentialed and experienced behavioral health
professionals must exercise their independent
professional judgment when providing behavioral health
care services to our members.
Referrals for evaluation and/or treatment of chemical
dependency and mental health issues will be reviewed
by a psychiatrist or licensed clinician to determine the
appropriate level of care.
For current information on our medical necessity criteria
or Clinical Policy Bulletins, visit Aetna.com/health-
care-professionals/clinical-policy-bulletins.html for
our Clinical Policy Bulletins page.
If you need hard copies of any of Aetna Behavioral Health
utilization management criteria or CPBs, call us at
1-888-632-3862 (TTY: 711).
Some states have specific requirements or laws in place
for practitioners and facilities. For more information on
state-specific requirements, see our public website.
79
Clinical practice guidelines (CPGs)
Consult behavioral health CPGs as you care
for patients
The National Committee for Quality Assurance (NCQA)
requires health plans to regularly inform practitioners
about the availability of CPGs.
The following behavioral health CPGs are based on
nationally recognized recommendations and
peer-reviewed medical literature. We adopt and
encourage the use of CPGs to help practitioners in
screening, assessing and treating common disorders.
Recognized professional practice societies publish
recommended guidelines. Before we adopt each
guideline, we review relevant scientific literature and get
practitioner input through our Quality Advisory
Committee. Network practitioner feedback then goes to
a National Quality Oversight Committee for adoption.
Once implemented, we review each guideline at least
annually for continued applicability and update them as
needed. We report guideline changes through our online
newsletter, OfficeLink Updates, posted on the
newsletters page of our public website.
How the guidelines help in clinical decision making
When used in clinical decision making, adherence to these
recognized guidelines helps to ensure that care authorized
for acute and chronic behavioral health conditions meets
national standards for excellence. We measure adherence
through use of the Healthcare Effectiveness Data and
Information Set (HEDIS®) measures.
Our adopted guidelines are intended to support, not
replace, sound clinical judgment. We welcome your
feedback and will consider all suggestions and
recommendations in our next review. You can
contact our Quality Management department at
QualityImprovement2@Aetna.com.
To support clinical decision making, we provide all
adopted practice guidelines to our behavioral health staff
and distribute them to contracted network professionals
when requested to do so.
Behavioral health clinical practice guidelines
we currently adopt:
• American Academy of Pediatrics Clinical Practice
Guideline for the Diagnosis, Evaluation, and
Treatment of Attention-Deficit/Hyperactivity
Disorder in Children and Adolescents
• VA/DoD Clinical Practice Guideline for the
Management of Major Depressive Disorder (MDD)
(2022)
• American Society of Addiction Medicine (ASAM)
Clinical Practice Guideline on Alcohol Withdrawal
Management (2020)
• American Society of Addiction Medicine (ASAM)
National Practice Guideline for the Treatment of
Opioid Use Disorder (2020)
• APA Practice Guideline for the Treatment of
Patients with Schizophrenia, Third Edition (2022)
There are several other behavioral health guidelines
to help support your patient care decisions on the
APA website.
For a copy of a specific CPG, call us at 1-888-632-3862
(TTY: 711).
80
Discharge review
Discharge planning includes all of the following
components:
• If a patient needs to be admitted to a different level of
care, discharge information will be provided to the
health care professional/facility at the time of referral for
admission.
• Facilities will designate a clinical staff member
to be responsible for coordinating discharge
planning activity.
• A written discharge plan must exist for each member,
and discharge planning should begin at the time
of admission.
• Where required, the inpatient facility, partial hospital
program, intensive outpatient program or other involved
health care professional will obtain a release of
information from the member that meets all state and
federal confidentiality regulations for the purpose of
coordinating care with the current treating providers. If
a release is obtained, the provider will facilitate
coordination of care and collaboration with the primary
care practitioner and/or other appropriate health care
specialist.
• Facilities should arrange for follow-up appointments
within seven days for each member discharged from an
inpatient stay. We also ask that health care
professionals to schedule such appointments
within seven days.
Continuity and transition of care
We may allow members to continue care for a specified
period of time with a behavioral health care professional
who has left the network. This will ensure that the
member’s course of treatment isn’t interrupted.
The length of time may vary and depends on regulatory
requirements, company policies, and the health care
professional’s willingness to continue to treat the
member. Company policy states that participating
providers leaving the network will work with us to
transition the member to a participating provider when
network benefits are requested and the care will exceed
the 90-day transition period. A health care professional
may not continue to care for a member under the
network benefit if we determine that a quality-of-care
issue may negatively impact the member’s care.
Inpatient level of care
Members who, at the time of enrollment, are being
treated at an inpatient level of care should complete their
single, uninterrupted course of care under the benefits
plan or policy that’s active at the time of admission.
All other levels of care
Patients who have met certain requirements are allowed
to continue an “active course of treatment” with a
nonparticipating practitioner. They can continue for up to
90 days without penalty, within the benefits limitations, at
the new or preferred plan benefits level as outlined in the
provider contract. In some states, regulatory
requirements may mandate that we continue coverage
beyond 90 days.
Collaboration and coordination of care
We appreciate the importance of the therapeutic
relationship and strongly encourage continuity,
collaboration and coordination of care. Whenever a
transition-of-care plan is required, whether the transition is
to a less intensive level of care or to another outpatient
provider, the transition is designed to allow the member’s
treatment to continue without disruption whenever possible.
We also believe that collaboration and communication
among providers who are participating in a member’s
health care are essential for the delivery of integrated,
quality care. There are several ways to ensure continuity,
collaboration and coordination of care, including:
81
• Ambulatory follow-up
Members being discharged from an inpatient stay
should have a follow-up appointment scheduled before
discharge. The appointment should occur within seven
days of discharge.
• Emergency department follow-up
Members seen in an emergency department setting for
a behavioral health condition or for alcohol or other
drug abuse or dependence should have a follow-up
appointment within 7 days of discharge. Emergency
department staff should assist with appointment setup
if possible. Behavioral health care professionals should
have available appointments within 7 days for members
recently treated in an emergency department.
• Timely and confidential exchange of information
With written authorization from the member, it’s
important that you communicate key clinical
information in a timely manner to all other health
care providers participating in a member’s care,
including the member’s primary care practitioner.
• Timely access and follow up for medication
evaluation and management
Members should receive timely access and regular
follow-up for medication management.
Behavioral health care professional responsibilities
for all levels of care
• Explain to the member the purpose and importance of
communicating clinical information and coordinating
care with other relevant health care providers treating
the same patient.
• Obtain written authorization from the member to
communicate significant clinical information to other
relevant providers.
• Obtain, at the initial treatment session, the names and
addresses of all relevant health care providers involved
in the member’s care.
• Subject to applicable law, include the following in the
Authorization to Disclose document signed by the
member in both outpatient office and higher-levels-of-
care settings:
- A specific description of the information to
be disclosed
- Name of the individual(s) or entity authorized to make
the disclosure
- Name of the individual(s) or entity to whom the
information may be disclosed
- An expiration date for the authorization
- A statement of the member’s right to revoke the
authorization, any exceptions to the right to revoke
and instructions on how the member may revoke
the authorization
- A disclaimer that the information disclosed may be
subject to re-disclosure by the recipient and may no
longer be protected
- A signature and date line for the member
- If the authorization is signed by the member’s
authorized representative, a description of the
representative’s authority to act for the member
If needed, an acceptable Behavioral Health/Medical
Provider Communication Form is located at Aetna.com
in the “For Providers” section.
• Contact the member’s primary care practitioner when a
member enters care and promptly when there is an
emergency or, with member consent, under
circumstances such as the following:
- Medical comorbidities and/or medication interactions
are a possibility
- Clinical information needs to be exchanged to aid in
diagnosis and/or treatment
- Primary care practitioner or specialist support for a
treatment plan would enhance member compliance
and/or treatment outcome
- Primary care practitioner or specialist has requested
immediate feedback
• Upon obtaining appropriate authorization, communicate
in writing to the primary care practitioner or other
appropriate specialist, at a minimum, at the following
points in treatment:
- Initial evaluation or assessment
- Significant changes in diagnosis, treatment plan or
clinical status
- When medications are initiated, discontinued or
significantly altered
- Termination of treatment
It’s recommended that communication occur within
two weeks of the above situations.
82
• Work with medical practitioners to support the
appropriate use of psychotropic drugs.
• Collaborate with our Patient Management staff to
develop and implement discharge plans before the
member is discharged from an inpatient setting.
• Cooperate with follow-up verification activities and
provide verification of kept appointments when
requested, subject to applicable federal, state, and local
confidentiality laws.
• Work with us to establish discharge plans that include a
post-discharge scheduled appointment within seven
days of discharge from an inpatient stay or an
emergency department visit.
• Notify us immediately if a member misses a
post-discharge appointment.
• Promptly complete and submit a claim for services
rendered, confirming that the member kept the
after-care appointment.
• Provide suggestions to us on how we can continue to
improve the collaboration-of-care process.
We annually audit random behavioral health care
professional records to check for communication and
coordination with primary care physicians and other
behavioral health providers and appropriate specialists.
The communication should either be in the form of a
professional letter or in a format that we accept.
Helpful tips
There is a difference between how behavioral health
practitioners share information with medical providers
and how medical providers share information among
themselves.
For behavioral health information such as general
progress reporting and sharing of details like medication
lists, a signed release may be required by relevant
federal or state law. This release may be required even if
the medical provider seeking the information is also the
one that referred the member to the behavioral health
provider. State and/or other laws may apply. Learn more
about mental health HIPAA requirements and
substance use disorder requirements.
Psychotherapy notes that contain the content of
conversations are not covered under a general release.
Psychotherapy notes require a separate release
of information.
Confidentiality laws govern what and how information
can be shared, and they vary by state. We encourage
both behavioral health and medical providers to find
out about and follow their state regulations.
To enhance coordination of care, obtaining a release of
information from your patient is one way to facilitate
information sharing with other providers and practitioners.
Quality programs
Quality program overview
We’re committed to a continuous quality improvement
program and encourage your involvement. The Aetna
Behavioral Health Quality program includes:
• A utilization management program
• Quality improvement activities
• Screening programs
• Condition management programs
• Member and provider experience surveys
• Provider treatment record review studies*
• Oversight of availability and access to care
• Member safety
• Complaint, nonauthorization and appeal processes
• Medical necessity criteria
• Clinical practice guidelines
• Investigations of potential facility and practitioner
quality-of-care concerns
Participating behavioral health care professionals are
required to support and cooperate with our Aetna
Behavioral Health Quality program, be familiar with our
guidelines and standards, and apply them in their clinical
work. Specifically, behavioral health care professionals
are expected to:
• Adhere to all Aetna policies and procedures, including
those outlined in this manual
• Cooperate with quality improvement activities
• Communicate with the member’s primary care
physician and any specialists (after obtaining a
signed release)
• Adhere to treatment record review standards, as
outlined in Appendix A on page 89 of this manual
• Respond in a timely manner to inquiries by our
behavioral health staff
• Cooperate with our behavioral health
complaint process
• Adhere to continuity-of-care and transition-of-care
standards when the member’s benefits are exhausted
or if they leave the network
• Cooperate with onsite audits or requests for
treatment records
• Return completed annual provider surveys
when requested
• Participate in treatment plan reviews or send in
necessary requests for treatment records in a
timely fashion
*FOR RECORD REVIEW STUDIES: These are completed for specific states where mandated by law.
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• Submit claims with all requested
information completed
• Adhere to patient safety principles
• Comply with state and federal laws, including
confidentiality standards, by maintaining the
confidentiality of member information and records
Annual quality program information and program
evaluation results are detailed on the Quality
Management & Improvement Efforts page on our
website. If you want a hard copy of our quality program
evaluation and don’t have Internet access,
• HMO and Aetna Medicare Advantage plans:
1-800-624-0756 (TTY: 711)
• All other plans: 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
Participating physicians and behavioral health care
professionals may use different types of accessible
medical diagnostic equipment. Or they may ensure they
have enough staff to help transfer the patient, as may be
needed, to comply.
Participating behavioral health practitioner
treatment record review criteria and
best practices
Each year, our quality management program randomly
selects Aetna Behavioral Health network practitioners,
in states where it is required, to participate in our
treatment record review. This audit procedure is a key
part of our quality program. It’s important for the network
to comply with standards set by Aetna Behavioral Health,
our customers, and external agencies.
Your Aetna Behavioral Health Agreement requires that
you participate in our quality management program.
Refer to Appendix A on page 89 of this manual for our
treatment record review criteria and best practices.
Or contact us at QualityImprovement2@Aetna.com
for a copy.
California Assembly Bill 2193 requires maternal
mental health screening
As of July 1, 2019, California Assembly Bill (AB) 2193
requires all licensed health care practitioners who
provide prenatal or postpartum care to a patient to
screen or offer to screen mothers for maternal mental
health conditions. Mental health concerns include not
only depression but conditions like anxiety disorders and
postpartum psychosis that are often missed or mistaken
as “normal” within pregnancy and postpartum periods.
Careful screening can identify those with mental health
conditions and improve the outcome for at least two
patients, if not the whole family.
Practitioners serving Aetna® members can use the
following screening tools:
• The Pfizer Patient Health Questionnaire-9 (PHQ-9)
is appropriate for prenatal screening. This is available
for download at no cost.
• The Edinburgh Postnatal Depression Scale is for
postnatal screening. This is available at no cost.
Scoring references are included for each, and
recommendations are made below. However, the final
determination for referral to treatment resources belongs
to the screening/treating professional.
For prenatal screening with the PHQ-9, any score
under 4 requires no immediate action. For a score of
5 to 14, it is recommended to refer the member to a
behavioral health counselor via the Member Services
number on the member ID card (ask for
AetnaBehavioral Health customer service). And for a
score of 15 or over, refer directly to Aetna Behavioral
Health condition management services by calling
1-800-424-4660 (TTY: 711).
For postnatal screening with the Edinburgh Scale,
any score from 7 to 13 warrants a referral to Aetna
Behavioral Health, which can then make referrals to
behavioral health providers. Any score of 14 or
above suggests a referral directly to Aetna Behavioral
Health condition management services by calling
1-800-424-4660 (TTY: 711).
Note: Scores of 1 or higher on question #10 (self-harm)
should be referred to Aetna Behavioral Health condition
management services immediately for follow-up.
These screening services are reimbursable. Submit
your claim with the following billing combination: CPT
codes 96127 or G0444 (brief emotional and behavioral
assessment) in conjunction with diagnosis code Z13.31
(screening for depression).
Behavioral health screening programs
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. When our clinicians assess a
case involving opioid dependence, they discuss the
potential benefits of adding naloxone (common brands
include NARCAN® and EVZIO®) to the member’s
treatment plan as an intervention, in the event of relapse
and future overdose.
Naloxone reverses the effects of an opioid overdose.
Providing naloxone rescue kits to laypeople reduces
overdose deaths, is safe, and is cost effective. Other
elements supporting this potentially life-saving
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intervention include telling patients and their family and
support network about signs of overdose and about
administering naloxone.
Coverage of naloxone rescue kits varies by individual
plans and can be verified by calling the number on the
member ID card. We waive copays for the naloxone
rescue medication NARCAN for fully insured
commercial members.
Refer patients to our Complex Case
Management program
Complex case management is for members with
complex conditions who need extra help understanding
their health care needs and benefits. Our behavioral
health clinical team works with members to identify those
who may have a coexisting behavioral health and/or
substance use disorder diagnosis We also help them
access community services and other resources. The
program offers an inclusive process for the member, the
caregiver, the providers and Aetna®. Available for
Commercial, Medicare, and Medicare-Medicaid
Dual-eligibility Special Needs (D-SNP) members.
These members will receive:
• An initial screening for coexisting mental health and
substance use disorders using evidenced-based
screening tools
• A individualized care plan (if the screening shows the
co-existing conditions)
• A behavioral health care manager who, as a part of the
care team, will help maintain continuity of care
Program goals
We want to help produce better health outcomes while
managing health care costs. Let’s work together to meet
these goals.
Program referrals
Know a member who could use extra help? Program
referrals are welcome from many sources, including:
• Primary care physicians
• Specialists
• Facility discharge planners
• Family members
• Internal departments
• The member’s employer
Help these members get the care they need — Make
a referral
• Call: 1-800-424-4660 (TTY: 711)
• Email: AetnaBehav[email protected]
• For Medicare-Medicaid Dual-eligibility Special Needs
Program (D-SNP) members — Refer to Aetna D-SNP
Resources
• Aetna emotional well-being resources
• U.S. Centers for Medicare & Medicaid Services
Roadmap to Behavioral Health
• U.S. Substance Use and Mental Health
Services Administration
Depression screening for pregnant and
postpartum women
We work with our medical management team to help
identify depression and behavioral health factors for
pregnant women. The Aetna Maternity Program gives
educational support to members and providers. We help
them reach their goal of a healthy, full-term delivery.
Program elements
• The clinical case management process focuses on
members holistically. This includes behavioral health
and comorbidity assessment, case formulation, care
planning, and focused follow-ups.
• The Aetna Maternity Program refers members with
positive depression or general behavioral health
screens to behavioral health condition management if
they have the benefit and meet the program criteria. We
assess members who have enrolled for any need,
including depression. We case manage members with
a history of any behavioral health issues, as well as a
positive depression screening. We make postpartum
calls to screen for depression. Then, we refer members
to their behavioral health benefit and providers as
appropriate, based on our assessment and screening.
• A behavioral health specialist supports the Aetna
Maternity Program team. They help enhance effective
engagement and identify members with behavioral
health concerns.
• Aetna Maternity Program nurses reach out to members
who have lost their babies to offer condolences and
behavioral health resources.
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How to contact us
• Members and providers can call
1-800-272-3531 (TTY: 711) to verify eligibility or
register for the program. Members can complete
enrollment with a representative, and you can also refer
members by calling this number. This includes
members who are pregnant, as well as members
who have experienced a loss.
• Members can also enroll online through their
member website.
Learn more about the Aetna Maternity Program.
Screening, Brief Intervention and Referral to
Treatment (SBIRT)
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 encourages use of the SBIRT model, which
calls for community-based screening for health risk
behaviors, including substance use.
We’ll reimburse you for screening patients for alcohol
and substance use disorder, providing brief intervention,
and referring them to treatment. You can help increase
the adoption of the SBIRT process in your practice. The
patient must 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 use disorders conditions, as well as outcomes
for patients, families and communities.
Click here to get started.
Helpful app screens for abuse
The SBIRT app is available as a free download.
The app provides evidence-based questions to screen
for alcohol, drugs 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.
Adverse incident reporting
We investigate reports of potential quality-of-care
concerns, which include any adverse incident that takes
place while a member is in care. Examples of potential
quality-of-care concerns include, but aren’t limited to any
completed suicide, serious suicide attempt, or homicide
that takes place within 30 days of discharge from care;
violent member behavior; or adverse outcomes requiring
hospitalization from psychotropic medication. Behavioral
health care professionals and facilities are required to
inform us (using the phone number listed on the member
ID card) as soon as they become aware of a potential
quality-of-care concern for any member in their care.
Teladoc® and other telemedicine services
Telemedicine is the use of telecommunications and
information technology to provide clinical health care
from a distance. It’s used to overcome distance barriers
and improve access to services. There are some states
that have mandates that require coverage of
telemedicine services for fully insured members.
Aetna® Behavioral Health offers telemedicine services to
all commercial fully insured members and to all
commercial self-insured plan sponsors, unless those self-
insured plan sponsors opt out of telemedicine services.
Providers must act within the scope of their license and
ensure that they have the proper licensure based on
state requirements.
National principles of care
In November 2017, we were one of 16 major health care
payers to commit in writing to the National Principles of
Care for Substance Use Treatment. The principles
are derived from the Surgeon General’s Report on
Alcohol, Drugs, and Health and are backed by
three decades of research.
We support these principles, and our goal for all
our members is that they receive these services:
1. Universal screening for substance use disorders
across medical care settings
2. Personalized diagnosis, assessment and
treatment planning
3. Rapid access to appropriate substance use
disorder care
4. Engagement in continuing long-term outpatient care
with monitoring and adjustments to treatment
5. Concurrent, coordinated care for physical and
mental illness
6. Access to fully trained and accredited behavioral
health professionals
7. Access to The U.S. Department of Food and Drug
Administration (FDA)-approved medications
8. Access to non-medical recovery support services
Learn more here.
Along with health care providers and the broader
community, we were involved on the task force to
implement needed changes to confront the opioid
crisis. We continue to partner with providers to help
implement these principles, including establishing
measurements of the adoption of these eight key
principles. We believe that universal screening is
important to identification of needs for substance
use care. And medication-assisted treatment
is critical in the delivery of high-quality,
evidence-based care.
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Member experience survey
Another aspect of our quality program and the services
we provide to our members is the member experience
survey. The results are analyzed to create and implement
improvement activities. The effectiveness of the activities
are monitored and assessed annually. We get feedback
from our members at least annually. The survey covers
the following areas:
• Ease of accessibility to our staff and our
network providers
• Availability of appropriate types of behavioral
health practitioners, providers and services
• Acceptability (cultural competence to meet
member needs)
• Utilization management process
• Coordination of care
We also annually evaluate member complaints, appeals
and denials. We collect data in these categories:
• Quality of care
• Access
• Attitude and service
• Billing and financial issues
• Quality of the practitioner’s office site
Practitioner survey
The practitioner experience survey is an additional
quality program activity to get feedback on satisfaction
with the services we provide. We obtain feedback from
behavioral health care professionals annually, and the
survey covers:
• Utilization management process
• Availability and accessibility (self-report)
• Continuity and coordination of care
• Referral to complex case management program
Working electronically
with us
Electronic solutions for health
care professionals
We offer a variety of easy-to-use electronic options that
are cost-effective and streamline the administrative
process. They make it easy for you to submit eligibility
and benefits inquiries, precertification requests, claims,
and claims status inquiries. These transactions reduce:
• Clerical, administrative and training costs
• Phone calls and reimbursement time
• Paper claims, forms, faxes and duplicate billing
• Errors, lost claims and multiple claims
office addresses
If you don’t use our provider portal, we also work with
various vendors and clearinghouses to offer a suite of
products ranging from no-cost, stand-alone solutions to
integrated systems for electronic transactions. Product
options are available through the internet, by computer
software and by telephone.
If spending less time on the phone and having the
flexibility to submit electronic transactions 24 hours a
day, 7 days a week would benefit your office, we invite
you to learn more about our vendor and clearinghouse
connectivity options.
Go to Aetna.com/provider/vendor to view our
vendor list.
Our provider portal
Our provider portal is a great resource.
You can:
• Check eligibility and benefits
• Send professional claims
• Request precertification
• Look up claims status and precertification
• Get electronic copies of Explanation of
Benefits statements
• Access your patients’ personal health records
• Upload clinical information that’s needed for the
precertification process
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You can also:
• Use our cost estimator tool to get a reliable
estimate of your patients’ out-of-pocket expenses
and our payment
• Access resources and tools for behavioral health
providers, such as clinical practice guidelines
• Access pharmacy materials, including formulary
information, pharmacy clinical policy bulletins, and
pharmacy forms
Remember: you can file claims electronically
Filing a claim electronically is easy. Some practice
management or hospital information systems
establish electronic claims submission based on
mailing addresses within claims records or billing
systems. As you validate and update your Aetna®
mailing information, ensure that all Aetna claims are
flagged in your system for electronic submission.
Contact your vendor for help with system setup.
Go to Availity.com to register
or sign in to our provider portal.
Provider data changes
We require that you tell us of data changes within
14 days of the date of the change. Update your profile
online, quickly and easily, on our provider portal.
Registered users can also update their information
on the site.
This process takes only a few minutes to complete.
You can easily update addresses, affiliations and
demographics. Following submission, you’ll get
a confirmation screen that shows that changes will
be made in seven to ten business days.
• HMO and Aetna® Medicare Advantage plans call:
1-800-624-0756 (TTY: 711).
• All other plans call: 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
• All plans can fax the information to us at
860-975-1578 (Attention: MDP Alignment)
All tax ID number changes/additions (unless you’re
joining an existing Aetna health care professional
group) require you to fax a copy of your W-9 form
to 859-455-8650.
How to find this manual online
We update this manual as needed to ensure you have
the most up-to-date, accurate information. If you’re
not currently viewing this document online, you can
find it at Aetna.com in the “For Providers” section, under
Provider Education & Manuals.
If you want a hard copy of this
manual and don’t have
Internet access, call us at:
1-800-624-0756 (TTY: 711)
for HMO-based and Aetna
Medicare Advantage plans
1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
for all other plans
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Appendix A: Aetna® Behavioral Health treatment record
review criteria and best practices
N Y N/A
Criteria
Number
Criteria Description
A. General record/documentation components
N Y 1 Record is legible to someone other than the writer (if record is not legible, all
questions are marked “N” and review ends).
N Y 2 Member’s contact and demographic data is documented (examples: address,
gender, date of birth, home phone numbers, emergency contact, marital/legal
status, and guardianship, as applicable).
N Y 3 Member’s name or unique identifier appears on every page.
N Y 4 All entries in the record are dated and contain the author’s signature or
electronic identifier with title (if applicable), and credentials/degree.
N Y 5 There is a signed release form for communication with a primary care
practitioner and/or other medical or behavioral health practitioners. If not, there
is documentation that the member declined to sign releases or is not currently
under the care of other providers.
N Y 6 There is a signed Consent for Treatment form.
B. Initial assessment and treatment plan
N Y 7.1 There is documentation of a presenting problem description including history,
current symptoms and behaviors, problem onset and problem development.
N Y 7. 2 There is documentation of the application of a standard assessment tool(s)
(examples include PHQ-9, GAD-7) to evaluate severity of symptoms and/or to
evaluate progress toward goals.*
N Y 8.1 There is documentation of a mental status examination (MSE).
N Y 8.2 As part of the MSE, there is documentation of a risk assessment, including
presence or absence of suicidal or homicidal thoughts and history of suicidal
actions.
N Y N/A 8.3 For members who have a history of suicidal thoughts/actions, there is a safety
plan documented which includes member self-management activities and an
emergency or crisis response service.*
N Y N/A 9.1 There is documentation of a substance use assessment, including past and/or
current substances used, or documentation that member has no substance use
history.
N Y N/A 9.2 Substance use history details such as frequency, duration and amounts are
documented as applicable.*
N Y 10.1 There is documentation of a behavioral health treatment history, or
documentation that member has no treatment history.
*New criteria added in 2023.
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N Y N/A
Criteria
Number
Criteria Description
N Y N/A 10.2 Behavioral health treatment history details, such as type of care (inpatient/
outpatient, therapy/medication management), duration and efficacy, are
documented as applicable.*
N Y N/A 11 There is documentation of family, legal, educational, cultural and/or other social
variables as they relate to the presenting problem and/or treatment plan.
N Y 12 There is documentation of a medical history including medical conditions,
medications and allergies as applicable. Or there is documentation that patient
has no history of health problems.
N Y 13 There is a behavioral health diagnosis(es) documented.
N Y 14.1 There is documentation of a complete treatment plan, which includes objective
and measurable goals and criteria used to evaluate member’s readiness for
discharge.
N Y 14.2 Each goal relates to the presenting problem(s)/diagnosis(es) and includes
specific steps or activities.*
N Y 14.3 Goals include a time frame for evaluating progress, and there is documentation
indicating assessment of progress within those time frames.*
N Y N/A 15 For children and adolescents: There is documentation of a developmental
history (examples are prenatal and perinatal events or physical, psychological,
social, intellectual, academic and educational history).
CA members only (Autism Spectrum Disorders) (reference California Code of Regulations Title 28 CCR 1300.67.1(e); 28
CCR 1300.80(b)(4); 28 CCR 1300.80(b)(5)(E); 28CCR 1300.80 (b)(6)(B); 28 CCR 1374.73); non-CA members score “N/A”
N Y N/A 16 CA members only: If member is 0-6 years of age, there is documentation of
screening for Autism Spectrum Disorder.
N Y N/A 17 CA members only: For members with an Autism Spectrum Disorder diagnosis,
there is documentation to support this diagnosis.
N Y N/A 18 CA members only: The treatment plan reflects evidence-based therapies for
Autism Spectrum Disorder.
C. Follow-up documentation
N Y N/A 19 For patients with a history of suicidal/homicidal thoughts/actions, or patients
who are otherwise at risk: There are risk assessments documented at every
session, with interventions (crisis care, facility admission, etc.) documented as
indicated.
N Y 20 There is a progress note documented for every session.
N Y N/A 21 If member’s permission was granted, there is documentation of continuity and
coordination of care between primary behavioral health clinician and other
behavioral health specialist(s) or consultant(s).
*New criteria added in 2023.
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N Y N/A
Criteria
Number
Criteria Description
CA members only (Autism Spectrum Disorders) (reference California Code of Regulations Title 28 CCR 1300.67.1(e); 28
CCR 1300.80(b)(4); 28CCR 1300.80(b)(5)(E); 28CCR 1300.80 (b)(6)(B); 28 CCR 1374.73); non-CA members score “N/A”
N Y N/A 22 CA members only: For pediatric members with an Autism Spectrum Disorder
diagnosis, there is documentation of collaboration, consultation and/or
continuity of care.
CA members only (reference California Code of Regulations Title 28 CCR 1300.67.04(c)(4)(A) and 28 CCR 1300.70);
non-CA members score “N/A”
N Y N/A 23 CA members only: There is documentation of the patient’s preferred language.
N Y N/A 24 CA members only: If the member’s preferred language is not English, there is
documentation of an offer of a qualified interpreter.
N Y N/A 25 CA members only: If interpretation services were offered, there is documentation
that the member accepted or declined the offer of a qualified interpreter.
D. Prescribing practitioner documentation (These questions score as “N/A” for all non-prescribing practitioners.)
N Y N/A 26 Prescribing practitioners only: There is documentation of current
psychotropic medications, dosages and dates of recent medication changes.
N Y N/A 27 Prescribing practitioners only: There is documentation of past psychotropic
medication trials and efficacy of those trials, or documentation that the member
has not previously been prescribed psychotropic medication.*
N Y N/A 28 Prescribing practitioners only: There is documentation of member education
on the risks and benefits of the prescribed medications, and documentation
that the member understands the information. There is also documentation
reflecting the member’s report of efficacy, side effect(s) and/or concern about
taking the medications as prescribed.
N Y N/A 29 Prescribing practitioners only: If the practitioner is prescribing a controlled
substance, there is documentation indicating that the practitioner reviewed the
state prescription database to assess the member’s past prescriptions for
controlled substances.*
*New criteria added in 2023.
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