Provider Bulletin AetnaMedicare.com Date

1 Provider Bulletin Date: Subject: Prior authorizations custodial Products: Dual SNP Long-Term Care From: Provider Relations Dear Provider , We're reaching out to inform you of our process when requesting a prior authorization for custodial long-term care facility benefits. Please review the attached notice for information about our authorization process. We appreciate your continued service to our members. Please feel free to fax us at 1-833-596-0339, or call 1-888-632-3862. Sincerely, Provider Relations CONFIDENTIALITY NOTICE: This message is intended only for the user of the individual or entity to which it is addressed and may contain confidential and proprietary information. If you are not the intended recipient of the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is prohibited.

2 If you received this communication in error, please notify the sender at the phone number above. NOTICE TO RECIPIENT(S) OF INFORMATION: Information disclosed to you pertaining to alcohol or drug abuse treatment is protected by federal confidentiality rules (42 CFR Part 2), which prohibit any further disclosure of this information by you without express written consent of the person to whom it pertains of as otherwise permitted by 42. CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. 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 ).

3 GR-69502 (1-20) Page 1 of 3. Provider Bulletin Prior authorization Custodial care authorizations This applies to members who are not receiving skilled services and are waiting for long-term care benefits. Next steps: 1. Complete the attached prior authorization form. For custodial requests, we need the actual date of admission and prior coverage payer information. 2. Fax it with clinical documentation and a completed Preadmission Screening and Resident Review (PASRR) to our prior authorization fax line at 1-833-596-0339 for review. 3. We'll respond with the authorization as quickly as possible. GR-69502 (1-20) Page 2 of 3. Prior Authorization Form Fax to: 1-833-596-0339. A determination will be communicated to the requesting Provider . Incomplete requests will delay the prior authorization process. Please include pertinent current clinical information and the completed PASRR to expedite this request.

4 Type of Request Non-Urgent/Standard (For Routine Services) Inpatient Patient Information Patient Name (last, first, MI) Date of Birth / /. Number Gender: Male Female Other Insurance? Name of Carrier Job Related? MVA? Yes No Yes No Yes No From - Requesting Provider Requesting Provider (Please Print) Tax ID Number Contact Person in Requesting Provider 's Office Telephone Fax ( ) - ( ) - Clinical Contact Person: Phone Name of PCP. ( ) - To - Where Will Patient Receive Services? Facility Requested PIN or TIN Address Telephone Fax ( ) - ( ) - Where services will be rendered? (Provide name of facility, if other than Provider office or patient's home). Today's Date Tentative Date of Service/Admission Start Date End Date / / / / / / / /. Clinical Information ICD- 10 Codes: (required) ICD- 10 Description Comments Clinical Indications/Rationale for Request: To expedite a determination on your request for services, please attach clinical documentation/medical records and completed PASRR to support your request.

5 Attestation I hereby certify and attest that all information provided as part of this prior authorization request is true and accurate. Provider Signature Date GR-69502 (1-20) Page 3 of 3.