Provider Manual — State Supplement

1 Provider Manual State Supplement (10/21). Welcome to the Provider Manual . State Supplement 10. Medicare Dual-Eligible Special Needs Plans (D- snps ).. 10. Enhanced clinical review 10. ALASKA .. 10. Medicare Dual-Eligible Special Needs Plans (D- snps ) (effective 1/1/2022) .. 10. Enhanced clinical review 10. Complaints and 10. Obtaining fee schedule 10. Performance programs .. 10. All other topics .. 10. ARKANSAS .. 10. Medicare Dual-Eligible Special Needs Plans (D- snps ) (effective 1/1/2022) .. 10. Enhanced clinical review 10. CALIFORNIA .. 10. The Aetna Value NetworkSM 10. Access 11. Enhanced clinical review 11. California Language Assistance Program (LAP).. 11. Maternal mental health screening.

2 11. Screening tools ..11. Prenatal screening 12. Postnatal screening 12. Screening services are 12. Specific medical record criteria ..12. COLORADO ..12. Access CONNECTICUT ..12. Capitated programs ..12. Direct-access Enhanced clinical review Access and Provider termination patient Surprise bills ..13. 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. DELAWARE ..13. Capitated programs ..13. Direct-access Enhanced clinical review DISTRICT OF COLUMBIA .. 14. Physical Therapy (PT) and Occupational Therapy (OT) .. 14. OptumHealth .. 14. OptumHealth responsibilities.

3 14. Referral process for PCPs .. 14. Claims 14. FLORIDA .. 14. Medicare Dual-Eligible Special Needs Plans (D- snps ).. 14. Enhanced clinical review 14. 14. Medicare Dual-Eligible Special Needs Plans (D- snps ).. 14. Enhanced clinical review 14. Physical Therapy (PT) and Occupational Therapy (OT) .. 14. Claims 15. Chiropractic services .. 15. 15. Complaints and 15. Demographic data changes .. 15. Obtaining fee schedule 15. Performance programs .. 16. ILLINOIS .. 16. Enhanced clinical review 16. Access 16. Provider vs. member appeals .. 16. Specialty networks and narrow 16. Central Illinois region: Carelink St. John's Hospital, Springfield, 16. Carelink St. John's 16. Verifying in-network 16.

4 INDIANA .. 16. Enhanced clinical review 16. Access 16. IOWA ..17. Medicare Dual-Eligible Special Needs Plans (D- snps )..17. Enhanced clinical review 3. KANSAS ..17. Medicare Dual-Eligible Special Needs Plans (D- snps )..17. Enhanced clinical review KENTUCKY ..17. Enhanced clinical review Medicare Dual-Eligible Special Needs Plans (D- snps )..17. LOUISIANA ..17. Medicare Dual-Eligible Special Needs Plans (D- snps )..17. Enhanced clinical review MAINE ..17. Direct-access Enhanced clinical review Claims processing ..17. Subluxation chiropractic Women's Health and Cancer Rights Act of 1998 .. 18. Out-of-network (OON) referrals in relation to Title 24-A 4303(22) .. 18. MARYLAND .. 18. Enhanced clinical review 18.

5 Maryland Provider terminations (quarterly report) .. 18. Maryland Uniform Consultation Referral form .. 18. Claims 18. Access 19. 19. Capitated programs .. 19. Direct-access 19. Enhanced clinical review 19. Demographic data quarterly 19. Massachusetts-only requirements in MGL Chapter 175, Sec. 47FF, 47GG; MGL. Chapter 176G, Sec. 4Z; and the 4A A Bulletin 19. Pain management access plan ..20. MICHIGAN ..20. Enhanced clinical review MISSISSIPPI ..20. Medicare Dual-Eligible Special Needs Plans (D- snps )..20. Enhanced clinical review 4. MISSOURI ..20. Enhanced clinical review Medicare Dual-Eligible Special Needs Plans (D- snps )..20. Hospitalist programs in Kansas City and St. Peer-to-peer review time frames in Specialty networks and narrow St.

6 Louis metro area: Carelink St. Louis .. 21. Missouri counties .. 21. Illinois counties .. 21. Lab services ..21. Verifying in-network St. Louis Select Network (formerly Coventry PPO Select Network)..21. Verifying in-network MONTANA ..21. Enhanced clinical review NEBRASKA ..21. Medicare Dual-Eligible Special Needs Plans (D- snps )..21. Enhanced clinical review NEVADA .. 22. Medicare Dual-Eligible Special Needs Plans (D- snps )..22. NEW 22. Direct-access Access standards ..22. NEW JERSEY .. 22. Capitated programs ..22. Direct-access Medicare Dual-Eligible Special Needs Plans (D- snps )..22. Enhanced clinical review Pre-authorization ..22. Provider NEW 23. Capitated programs ..23. Enhanced clinical review Provider Discharge plans following inpatient substance use disorder treatment.

7 24. Provider contracting information ..24. Hospital nonbinding mediation ..25. Confidentiality of HIV-related information ..25. Policies ..25. 5. Quality Management (QM) program ..26. Quality strategy Quality management (QM) Quality Management (QM) program goals ..27. Accountability and committee structure ..28. Board of 28. National Quality Oversight Committee (NQOC).. 28. National Quality Advisor Committee (NQAC) .. 29. National Vendor Delegate Oversight Committee (NVDOC) .. 29. Medicare-Medicaid Plan (MMP) Delegation Oversight Committee (DOC) .. 30. Credentialing and Performance Committee (CPC).. 30. Provisionally credentialed providers (New York) .. 31. Practitioner Appeals Committee (PAC).

8 31. Required disclosure relating to out-of-network service and referrals ..31. Adverse reimbursement Claims processing time frames ..32. Coordination of Benefits (COB)..32. Claims practices: Provider claims submission time period ..32. Overpayment recovery: Provider challenges and extension to all Participating Provider and participating hospital reimbursement ..33. Participating hospital coding adjustments ..33. Rare disease Provider external appeals Surprise out-of-network claim ..34. NORTH CAROLINA ..34. Enhanced clinical review Medicare Dual-Eligible Special Needs Plans (D- snps )..34. Physical Therapy (PT) and Occupational Therapy (OT) referrals ..34. Specialist In-network specialist care.

9 34. Out-of-network specialist care .. 34. Physician accessibility standards ..35. Primary care physicians (PCPs) .. 35. Specialist physicians .. 35. OHIO ..35. Enhanced clinical review Medicare Dual-Eligible Special Needs Plans (D- snps )..35. Enhanced clinical review Specialist as Principal Physician Direct Access (SPPDA) program ..35. Program 6. Complaints and Obtaining fee schedule Performance programs ..36. PENNSYLVANIA ..36. Capitated programs ..36. Direct-access Enhanced clinical review Medicare Dual-Eligible Special Needs Plans (D- snps )..36. RHODE Direct-access Claims processing ..36. Demographic data changes ..36. SOUTH 37. Enhanced clinical review Physical Therapy (PT) and Occupational Therapy (OT) referrals.

10 37. Primary Care Physician Initial Lab Designation and Change Request SOUTH 37. Enhanced clinical review TENNESSEE .. 37. Enhanced clinical review Primary care physicians (PCPs)..37. Specialist physicians ..37. Additional physician accessibility requirements ..37. TEXAS ..38. Medicare Dual-Eligible Special Needs Plans (D- snps )..38. Access Gynecologists as principal physicians for the Women's Health Care Program ..38. How to bill ..38. Women's health: variations from the national program for the State of Specialists as PCPs ..39. Peer-to-peer process ..39. Utilization management timelines ..39. Utah networks .. 40. VERMONT ..40. Enhanced clinical review 40. 7. Enhanced clinical review 40.