Fall 2018 - AKSARBEN AAHAM
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Fall 2018 ©2017 Aetna Inc. 1
Websites Websites for health care professionals • www.aetna.com • Information on how to work with us, products & programs, resources for health care professionals and helpful links. • www.navinet.net • Secure provider portal with Information on member eligibility, claim status, EOBs, claim reconsiderations, secure emails to provider services, claim payment policies, claims reimbursement tool, claims payment estimator and much more! ©2017 Aetna Inc. 2
Aetna OfficeLink Updates – News you can use Aetna OfficeLink Updates delivers timely information for your practice or facility. The online newsletter is published in March, June, September and December. This is Aetna’s method for communicating changes to providers. • Inside each issue providers will find: - Updates to our precertification list - Clinical payment, coding and policy updates - Medicare information - Pharmacy information - Plan and product information - State specific news • Newsletters can be found by going to www.aetna.com, Health Care Professionals, Newsletters & News, Read OfficeLink newsletters and then Mid-America OfficeLink Update newsletter. ©2017 Aetna Inc. 3
Provider Manuals
Provider manuals about our policies and programs
• In January 2019, a new & improved Provider Office Manual will be released with more
user friendly features for providers!
• You can view and download these manuals:
– Office Manual for Health Care Professionals – Renaming to Provider Office Manual
– Region Specific Supplement Manual – 2nd quarter 2019 this will be a state specific drop down to
choose if there is information pertaining to your state only
– Behavioral Health Provider Manual
– Women’s Health Programs and Policies Manual
– Aetna Benefits Product Guide
– Quick Reference Guide
• Provider manuals can be found by going to www.aetna.com, Health Care
Professionals, Education & Manuals, Explore provider manuals
• Coventry Health Care provider office manuals are located on www.chcnebraska.com,
Services & Support, Providers, Document Library, Provider Manual
©2017 Aetna Inc. 4Educational Webinars Learn how to work with us electronically! We offer interactive, 45-minute webinars that walk you through how to use our online tools. How to register for webinars - Register online at www.aetna.com, Health Care Professionals, Provider Education & Manuals, Educational Webinars and click the Complete online webinar registration form link. - Send an email to eSolutionsTraining@aetna.com with the name and date of the webinar in the subject line. ©2017 Aetna Inc. 5
2019 Aetna plans offered
What plans are available in 2019?
• Aetna Plans will include
- Commercial HMO, PPO, POS, Open Access plans (Member IDs begin with a W)
- High Performance network commercial plans offered with the CHI Health ACO and
Nebraska Health Network high performance network
• Aetna’s CHI Health ACO product is currently offered in Buffalo, Dawson, Douglas, Hall, Howard,
Lancaster, Phelps, Saline, Sarpy counties in Nebraska and Pottawattamie county in Iowa.
• Aetna’s Nebraska Health Network high performance network is offered in Douglas, Sarpy and
Pottawattamie counties
- Aetna does not offer an individual product in 2018 or 2019 on or off the exchange.
Aetna Leap policies termed 12/31/17 (These member plan IDs began with a 1).
- Medicare plans for 2018 - Aetna Medicare in Nebraska is currently offered as a retiree
program for large group employers. (For these plans member IDs begin with a M)
Medicare
©2017 Aetna Inc. 62019 Aetna Signature Administrators & Meritain
Aetna Signature Administrators (ASA) contracts directly with
third party payers (TPA’s) to access Aetna’s PPO network.
For additional information on ASA, please visit
www.aetna.com
Meritain Health is an Aetna Company that offers the use of
Aetna’s National Networks.
For additional information, please visit www.meritain.com
©2017 Aetna Inc. 72019 Coventry plans offered
What plans will be available in 2019?
• In 2019 there will be no more commercial Coventry
Health Care of Nebraska plans offered. This logo
will no longer be seen on 2019 member ID cards.
• Claims run out for any Coventry plan will be 1 year from the termination of the plan or
group.
• First Health is the rental network for TPA clients to access. First Health is the network
but not the payer. For a current listing of First Health clients, please log into
www.directprovider.com
©2017 Aetna Inc. 8Aetna & Coventry Medicare Plans We’re changing our name to Aetna Aetna and Coventry have been the same company since 2013. But we’re now transitioning to one brand. Your provider contracts aren’t impacted by our name and logo change. To avoid confusion: • Ask for your patient’s ID card • Refer to the website and phone number on the card if you have questions Your existing Coventry contract is not affected by our name and logo change for plan(s). You’ll continue to be paid for covered services provided to Aetna Medicare Advantage members according to your Coventry Medicare contracted rates. ©2017 Aetna Inc. 9
Aetna & Coventry Medicare Plans
1/1/2019 Changes are –
• Coventry Health Care Medicare Advantage HMO plans are moving to Aetna platform.
This includes Coventry Health Care Total Care CHI Health Plan. These members will
have an Aetna logo on their card and member IDs will start with a 1.
• Claims run out for Coventry Health Care Medicare Advantage HMO plans will be
through 12/31/2019.
• Coventry Health Care Medicare Advantage PPO plans are staying on the Coventry
platform but will have a logo change. These members will have an Aetna Coventry
logo and member IDs will start with a 9.
©2017 Aetna Inc. 10Aetna & Coventry Medicare Plans
Key Differences in these Medicare plans –
• Claims addresses
• Provider Service Phone Numbers
• Mental Health Networks (Aetna Coventry will use MHNet and Aetna uses Aetna
Behavioral Health)
***It is important to check the back of every member’s ID card for all of the correct
above information.
©2017 Aetna Inc. 11Medicare Advantage Sample ID Card
CHI Health Total Care HMO is a
narrow network of providers.
Providers in this network participate
with UniNet PHO.
©2017 Aetna Inc. 12Medicare Advantage Sample ID Card ©2017 Aetna Inc. 13
Observation Policy Changes
Observation Policy Reminders
• Beginning 7/1/18, we updated our policy as follows:
• We no longer require notification for observation greater than 24 hours
• We no longer cover observation services that extend beyond 48 hours
• Observation is no longer reviewed for medical necessity and is not covered beyond 48 hours –
please see the payment policy within NaviNet for additional information
• March 2018 OfficeLink notification - http://www.aetna.com/healthcare-
professionals/assets/documents/olu-march2018.pdf
• Aetna Payment policies can be located within NaviNet – Claims, Policy Information, Claims
Payment & Coding Policies
©2017 Aetna Inc. 14Total Knee Arthroplasty Precertification Updates The Centers for Medicare & Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list on January 1, 2018. Code 27447: Arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) What this means You don’t have to perform all procedures on an outpatient basis. We consider the information you share about the member’s clinical circumstances, MCG® (Milliman Care Guidelines) and the member’s benefits coverage when you request an inpatient precertification admission. When precertification is given through a vendor program, that information is shared with us. You don’t have to contact us again for the inpatient precertification request. There may be cases when we request more clinical information in order to complete your inpatient precertification. Elective inpatient admissions require precertification. The National Precertification List can be found on aetna.com – Providers, Working with us, Precertification. If you have questions, call us using the precertification number listed on the member’s ID card. ©2017 Aetna Inc. 15
Correct Coding of Hospital Observation ©2017 Aetna Inc. 16
Pass through Billing – Modifier 90
• In June, 2017 we notified about how Aetna would deny pass-through billing for lab
charges from a non-facility provider. This policy went into place 10/1/17.
• The purpose behind this policy is to reimburse the provider performing the lab
service.
• Whenever possible, please use Quest Diagnostic Services or LabCorp for the most
cost effective option for Aetna members.
• Aetna Payment policies can be located within NaviNet – Claims, Policy Information, Claims
Payment & Coding Policies
©2017 Aetna Inc. 17Hospital Bill Type 141
• In October 2017, a new pass through billing policy went into effect not allowing
physicians to bill the lab services and required the rendering provider to bill.
• It was discovered that Aetna also had a policy in place that labs could not be billed by a
hospital and should be billed by an independent lab.
• Nebraska has put in a deviation from this policy as our state does not have enough
independent labs to support this policy.
• This deviation is in place and claims projects are currently underway for both Aetna
and Aetna Leap products.
©2017 Aetna Inc. 18Provider Services Provider Services should be the first point of contact for assistance with any questions or issues. • For Aetna please call 1-888-MD Aetna (888-632-3862) • For Coventry Medicare Advantage please call 1-866-901-4692 • For Coventry Health Care of Nebraska please call 1-800-288-3343 • For ASA, Meritain or First Health, please call the number on the back of the ID card Network Relations should only receive escalated issues and please include the following • Reference Number • Copy of EOB • Description of overall issue and what the expected payment or outcome is ©2017 Aetna Inc. 19
Questions?
DATE Provider Name Address Address Dear Provider: We’re changing our name to Aetna Aetna and Coventry have been the same company since 2013. We’re changing our name and logo, but our relationship with you and our members will stay the same. You and your patients may see either of these names or logos on communications we send to you. No action is needed You don’t have to take any action. Keep working with us and caring for our members as you always have. And, continue to send claims to the payor ID or address on the back of the member’s ID card. We’ll let you know of any future changes. ID Cards Starting January 1, 2019 when you see a member with an Aetna ID card that also indicates Coventry Advantra Silver HMO or CHI Health, the Enhanced Clinical Review Program will be managed through Evicore. Members with Aetna/Coventry ID cards will continue to have radiology precert managed by NIA. To avoid confusion • Always ask for your patients ID Card • Refer to the Payer ID (part of ID card) • Remember a PCP named may reflect either a provider or practice Our ID card reference guide is enclosed - for your office staff.
Same payment and contract rates
Your existing Coventry contract is not affected by our name and logo change for plan(s).
You’ll continue to be paid for covered services provided to Aetna Medicare Advantage
members according to your Coventry Medicare contracted rates. However, as we move
membership to our new operating platform, you may notice some minor changes in the
way some claims processes are handled.
We’ve included examples of some of the changes you may experience. If you are also a
contracted provider in the Aetna Medicare network, you’ll find that the changes you
experience will mirror the way that your Aetna Medicare claims are handled today.
Some potential differences you may see
Topic Aetna HMO Coventry Medicare products
Method for Medicare Fee Schedule rate is Medicare Fee Schedule rate may
determining based on the geographic location be based on criteria other than the
reimbursement of the servicing provider’s ZIP provider’s ZIP code (for example,
rate code. locality name).
New service New codes are valued at the New codes are valued at the
codes & current Medicare Fee Schedule current Medicare Fee Schedule
Medicare gap rate in accordance with rate in accordance with e
codes Policy and methodology described above. For methodology described above. For
timing of new codes not valued on the new codes not valued on the
updates. Medicare Fee Schedule, rate is Medicare Fee Schedule, the rate is
determined by the contractual determined by each Coventry
default rate or will default to health plan.
Aetna Market Fee Schedule if Medicare Fee Schedule updates
there is no contractual default. may occur at various times
Medicare Fee Schedule usually throughout the year as
updated in January of each year. determined by each Coventry
Health Plan.
Note: These variations are subject to the terms and conditions of your agreement.Precertification
At Aetna we work with MedSolutions dba eviCore healthcare to authorize many procedures
in our Enhanced Clinical Review program. These precertification programs apply to our
Aetna branded products.
Services that require pre-approval:
• High-tech outpatient diagnostic imaging procedures; this includes MRI/MRA, nuclear
cardiology, PET scan and CT scan, including CTA.
• Non-emergent outpatient stress echocardiography.
• Non-emergent outpatient diagnostic left and right heart catheterization.
• Insertion, removal and upgrade of elective implantable cardioveter defibrillator;
Cardiac Resynchronization Therapy-defibrillator and implantable pacemaker.
• Polysomnography (attended sleep studies).
• Interventional pain management.
• Musculoskeletal large joint (hip and knee) arthroplasty procedures.
No pre-approval is needed for these services:
• Inpatient radiology services
• Emergency room radiology services
• Outpatient radiology services other than those listed above
To get approval from MedSolutions dba eviCore healthcare, you can:
• Visit evicore.com
• Call 1-888-693-3211 during normal business hours
• Fax a request form (available online) to 1-888-693-3210
We’re here to help
To ensure a smooth transition, we’re starting the move on January 1, 2019. It’s important to
remember that not all Aetna Coventry Medicare membership will move to the new
platform at the same time.
If you have concerns about the manner in which your claims are being handled once this
move starts, call us at the number on the member ID card.
Aetna’s secure provider website is NaviNet®
Starting January 1, 2019, our NaviNet portal will be available to you for these plans. If you’re
not registered, take a few minutes to sign up today.Transactions and tools on our website
On our provider website, provider offices have access to many transactions and tools that
can help simplify your work day. To see a complete listing of what we offer visit our
overview page.
The “Workflows” section in the left navigation bar quickly navigates you to:
• Electronic transactions
• Claim EOB Tool
• Account Management Tools
• Update Provider Demographics
The “Resources” section on the right navigation bar offers quick links to content like:
• Accountable Care Solutions
• Clinical Policy Bulletins
• Precertification List
• Aetna Benefits Products
Claims and account management
You can submit professional claims for free, regardless of your participation status. You
can also inquire on individual claims, run claims reports and access claims policies.
The “Help” section from the top navigation bar to also offers many Customer Support
Resources like General Information, Security Officer User Guides, Aetna User Guides and
more.
Log in or register
• Existing users: Go to https://connect.navinet.net
• New users: Go to https://connect.navinet.net/enroll
Enter your username/password and select ‘Aetna Health Plan’ from the Health Plans
section in the left navigation bar.
Note: NaviNet supports all browser interfaces for Internet Explorer 8 or greater and
Macintosh.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company and its affiliates (Aetna).
©2018 Aetna Inc.You can also read
