Provider Manual - Aetna

1 Provider Manual Resources, policies and procedures at your fingertips S (9/21) Welcome to your Provider Manual Your Provider 5 Creating a diverse, equitable and safe 5 A word about 5 Here to help you .. 5 Changes and updates .. 6 New to the Aetna network? .. 6 Local network 6 Provider data 7 Updating your data helps patients find you .. 7 Medicare and commercial 7 Provider roster requirements .. 7 Helpful 9 Key contacts .. 10 Electronic Eligibility and benefits 12 Patient cost estimator* .. 12 Authorization adds, inquiries and 12 Referral add and 13 Claim Claim disputes and appeals .. 13 Claim status 13 Rules for electronic Electronic payment Online claims Explanation of Benefits (EOB) Electronic remittance advice (ERA).

2 14 Capitated providers ..14 Working through clearinghouse vendors: transactions by Our Aetna Benefits Products Joining our How to apply ..15 Credentialing (and recredentialing)..15 Health care How to check your status ..15 Radiology accreditation ..15 Provider identification Share your National Provider Identifier (NPI)..16 Aetna Provider identification number (PIN)..16 Accessibility standards and participation Primary care Provider (PCP) Specialty care Provider responsibilities ..16 Physician-requested member Medical clinical policy bulletins .. 17 17 Nondiscrimination .. 17 Members rights and responsibilities ..18 Advance directives and the Patient Self- Determination Act (PSDA)..18 Informed consent ..18 Physician-member communications policy ..18 Verifying member eligibility and 19 How to interpret a member ID card.

3 19 Member identification and verification of Digital ID Member ID Group enrollment Newborn Verifying benefits ..20 Verifying your network participation ..20 Precertification ..21 Emergencies ..21 Medical 21 Follow-up care after emergencies .. 21 Claims and billing ..21 Member 21 Billing members for noncovered services consent 21 Billing and balance-billing 22 Other billing situations .. 22 Initiating a collection action against a 22 Concierge 22 Claims 23 Electronic claims submission .. 23 Claims submission tips .. 23 Disagree with a claim decision?.. 23 Claims addresses .. 23 Clean claims .. 23 Coordination of 24 Coordination of benefits with commercial carriers .. 24 Coordination of benefits with Medicare coverage .. 25 Medicare estimation .. 26 Medicare and Medicaid dual eligibles .. 26 Medicare Part D plans.

4 26 Coordination of benefits with automobile insurance/ no-fault The National Advantage Program .. 26 Coding .. 27 Claims payment policy 27 A DRG interim 27 Overpayment recovery .. 27 Audits ..27 Hospital bill 27 Diagnosis-related group (DRG) audit .. 27 Implant audit .. 28 Prepay review .. 28 28 Where to send Aetna records .. 28 Medical records ..29 Record keeping .. 29 Participating practitioner medical record 29 organization .. 29 31 *The 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 ( Aetna ). 2 Communication .. 31 Records maintenance and 31 31 Member record access .

5 31 Privacy Referrals ..33 Referral Member s consent for nonparticipating providers referrals .. 33 Utilization management ..34 Utilization management and How to contact us about utilization management issues .. 35 Utilization review policies .. 35 How we determine coverage .. 35 Admissions protocol .. 36 Notify us of hospital admissions within one business day .. 36 All-products precertification 36 Member programs and resources ..37 Member 37 Care management .. 37 Disease 37 Aetna Healthy Lifestyle Coaching 37 Aetna Lifestyle and Condition Coaching program .. 38 Fitness programs for Aetna Medicare Advantage members .. 38 Women s health 38 Member resources .. 38 24-hour Nurse Line .. 38 Institutes of Excellence Institutes of Quality 38 Aetna Institutes Gene-based, Cellular and Other Innovative Therapies (GCIT ) Designated Networks.

6 38 Behavioral 38 Behavioral health access standards* .. 39 Screening for coexisting behavioral health and substance use disorders .. 39 How to make a 39 39 The Aetna Depression in Primary Care 39 Screening, brief intervention and referral to treatment (SBIRT) The Aetna Opioid Overdose Risk Screening Program ..40 Pharmacy management and drug Overview of the Pharmacy plan Drug List (formulary)..41 Commercial plans ..41 Aetna Medicare Advantage 41 Requirements for Part B drugs .. 41 CVS Caremark Mail Service Pharmacy .. 41 How your patients can learn CVS Specialty .. 41 Helping patients manage their therapies .. 42 Flexible payment options for out-of-pocket costs, when necessary .. 42 Treating complex diseases and chronic Ordering through CVS Specialty is Electronic prescribing .. 42 Pharmacy clinical policy Precertification.

7 43 Step Quantity Generic Medical exception and Performance Quality, accreditation, review and reporting Aexcel network of specialist Patient-centered medical home (PCMH) ..45 Physician pay for performance (P4P)..46 Clinical medical management ..46 Clinical practice and preventive service Clinical practice 47 Behavioral health clinical practice 47 Preventive services Case management .. 47 Coordination of care ..48 Importance of Sharing patient Accessing communication Transition of The four steps for requesting transition of Complaints and appeals ..49 Aetna Medicare Advantage plans**..50 Aetna Medicare health maintenance organization (HMO) plans and Aetna Medicare HMO Prime plans ..50 Aetna Medicare HMO plans with open access ..50 Aetna Medicare preferred Provider organization (PPO) plans and Aetna Medicare PPO Prime Aetna Medicare Advantage plans (HMO and PPO).

8 50 Aetna Medicare Advantage HMO Aetna Medicare Advantage PPO Home assessment 51 Quality improvement 51 Medicare prescription drug Transition-of-coverage (TOC) 52 Additional prescription drug plan 52 preferred Part D drug 53 Home Additional Aetna Medicare Advantage Physician-member communications Demographic data quarterly *Unless state requirements are more stringent. ** 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 50 of this Manual , for further information. 3 ..Collecting all Aetna Medicare Advantage plan member cost access to facilities and 55 access to 55 Medicare Outpatient Observation Notice (MOON) requirement.

9 55 Medicare Medical Loss Ratio (MLR) requirements .. 55 Advance directives .. 55 MA organization Determination (OD) Ban of Advance Beneficiary Notice of Noncoverage (ABN) for Medicare Advantage (MA)..56 Medicare prescription drug plan (PDP and MAPD) coverage determinations and exceptions process .. 57 Medicare Advantage (MA and MAPD) and Medicare PDP member grievance and appeal Obligation to respond to requests for Confidentiality and accuracy of member records 58 Coverage of renal dialysis services for Medicare members who are temporarily Direct access to in-network women s health specialists ..58 Direct- access immunizations ..58 Emergency Health-risk assessment .. 59 Receipt of federal funds, compliance with federal laws, and prohibition on discrimination .. 59 Provider Financial liability for payment for 59 Medicare Compliance Program 59 Standards of Conduct and Compliance Exclusion list screening.

10 60 The Patient Protection and Affordable Care Act (PPACA), implemented in The effective communication baseline rule ..60 Individuals qualifying for auxiliary supports and services ..60 Auxiliary support and service options ..61 Persons qualified to act as interpreters ..61 Oversight of your subcontractors ..61 What may happen if you don t comply ..61 Making sure you maintain Report concerns or Medicare access and CHIP Reauthorization Act (MACRA) reimbursement policy ..61 Temporary move out of the service Travel programs when members are away from home for an extended period .. 62 Plans rules and requirements must be followed .. 63 Urgently needed services .. 63 Physicians and other health care professionals and marketing of Aetna Medicare Advantage 63 Annual notice of 63 Claims and billing requirements ..64 Submitting Medicare claims and encounter data for risk Risk adjustment medical record validation.