Women's health programs and policies - Aetna
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Women’s health programs and policies
22.20.800.1 A (9/17)
aetna.com
Women’s
health
programs
This manual will help you
understand our women’s
health programs and policies.
And we’ll be right there
with you, throughout all
of life’s stages.
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).
2
Table of contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Obstetric policies and reimbursement . . . . . . . . 15
Key phone numbers and contacts . . . . . . . . . . . . . . . . . . 5 Global obstetric fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Online resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Perinatology services . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Reproductive genetic counseling . . . . . . . . . . . . . . . . . 19
Gynecologic programs, policies Rh immune globulin policy . . . . . . . . . . . . . . . . . . . . . . . 19
and reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Flu vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Primary and preventive gynecologic services . . . . . . . . 7 Postpartum visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Direct-access/prior authorization policies . . . . . . . . . 7 Non-emergency, non-obstetric medical care . . . . . . . 19
Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Spontaneous abortions . . . . . . . . . . . . . . . . . . . . . . . . . 20
Radiology services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Instructions for billing portions of prenatal care
Automatic studies for gynecologic services . . . . . . . . . . 7 and delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Cervical cancer screening services . . . . . . . . . . . . . . . . . . 7 High-risk pregnancy management enhancement . . . 20
Human papillomavirus (HPV) DNA screening . . . . . . . 7 Cell-free fetal nucleic acid screening . . . . . . . . . . . . . . 20
Breast health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 First and second trimester non-invasive screening
Referral policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 to provide individual risk assessment for
Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 fetal aneuploidy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Credentialing requirements for fetal aneuploidy
BRCA: genetic testing for breast and ovarian cancer . . . 8 screening involving nuchal translucency (NT)
How to get BRCA testing approval for a member . . . 8 measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Genetic counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Other services covered for individual risk
Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 assessment for fetal aneuploidy . . . . . . . . . . . . . . . . . 22
Capitated lab services for women’s health services . . . 9 Intramuscular progesterone therapy . . . . . . . . . . . . . . 22
HPV DNA testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Home births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
HPV vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Infertility program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Frequently asked questions . . . . . . . . . . . . . . . . . 23
Beginning Right® maternity program . . . . . . . . . . 11 Other online resources . . . . . . . . . . . . . . . . . . . . . . 26
Member eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Member enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Program content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Welcome packet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Second trimester educational mailing . . . . . . . . . . . . . 11
Third trimester educational mailing . . . . . . . . . . . . . . . 11
Pregnancy risk survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Case management of high-risk-pregnancy activities . . 12
Preterm labor education program . . . . . . . . . . . . . . . . . 12
Beginning Right follow-up . . . . . . . . . . . . . . . . . . . . . . . 12
African American preterm labor education program . . 12
Smoke-Free Moms-to-Be® smoking
cessation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Pregnancy and postpartum depression screening . . . 13
Diabetic case management for pregnant members . . 13
Other important notes . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Getting obstetric care . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Prenatal care access standards . . . . . . . . . . . . . . . . . . . 14
3
Introduction
Women’s health programs are This manual will help you understand our women’s
health programs and policies. Some of the programs
an important part of our may not be available to members who select a primary
medical management efforts. care physician (PCP) affiliated with an independent
practice association (IPA), physician medical group,
integrated delivery system or other provider group.
We offer programs that To determine eligibility, just contact us at the phone
number listed on the member’s Aetna ID card.
facilitate a holistic member We let you know about changes in policy through:
view, consider multiple diseases • Our Aetna OfficeLink Updates™ newsletter
and conditions across all • Our public website at aetna.com
benefits plans and deliver • Our secure provider website on NaviNet® at
individualized programs based https://navinet.navimedix.com.
on a member’s unique needs
and preferences.
4
Before you access the information in this manual, review Key phone numbers and contacts
these important highlights:
• Beginning Right maternity program
• Patient advocacy — Physicians are advocates on 1-800-272-3531
behalf of their Aetna patients. Read the “Member Rights • Infertility case management program
and Responsibilities” section of our Office Manual for 1-800-575-5999
Health Care Professionals. You’ll find it at
• Breast Health Education Center
https://navinet.navimedix.com.
1-888-322-8742
• Informed consent — Physicians are responsible for
• BRCA genetic testing program
providing their patients with all information relevant to
1-877-794-8720
their condition(s). This includes all health care
alternatives, even if an option isn’t covered by their • Provider Services
plan, as well as potential risks and benefits of each. - HMO-based and Medicare plans: 1-800-624-0756
• Patient emergencies — If our members need - All other plans: 1-888-MD-Aetna (1-888-632-3862)
emergency care, they’re covered 24 hours day, 7 days
a week, anywhere in the world. Online resources
• Providing medical information — Physicians are • Women’s health information — Visit the “Individuals
responsible for giving us the complete and accurate & Families” section of aetna.com. Then, under
medical information required (that is, diagnosis, clinical “Information & Resources,” click “Women’s Health.” Here
information and/or services provided) to make you’ll find general women’s health information and
appropriate coverage determinations. details on women’s health programs.
• Independent contracting — As indicated in all of our Topics include:
provider agreements, participating providers aren’t - Advice for moms-to-be
employees or agents of any Aetna affiliate.
- Understanding and treating breast and
• Information about coverage — If you’re unsure if ovarian cancers
a particular service is covered under a member’s plan,
- Helpful tips for every stage of a woman’s life
contact us using:
• Our secure provider website — Search for
- Our secure provider website at
physicians, hospitals and other health care
https://navinet.navimedix.com
professionals at https://navinet.navimedix.com.
- Our dedicated Provider Service Centers — for You can also access the site at aetna.com. Under
health maintenance organization (HMO)-based and “Health Care Professionals,” click “Secure Provider
Medicare plans, 1-800-624-0756; for all other Website.” Once on the site, register or log in with
plans, 1-888-MDAetna (1-888-632-3862) your user name and password. Features of this
• Appeals — You may appeal adverse benefits website include:
determinations and provider reimbursement decisions. - Online professional claims submission
Also, members and some physicians may have the (HCFA/CMS 1500) for physicians and
right to an external review if the circumstances of the physician groups
appeal meet certain criteria. To find out more about
our dispute and appeal process, just go to the “Health
Care Professionals” section at aetna.com. Then click
“Dispute & Appeal Process.”
5
- Data-entry screens for online claim inquiries • Pharmacy services and tools — Visit the “Health
and eligibility, and real-time referral and Care Professionals” section at aetna.com. Then under
precertification transactions “Products & Programs for Health Care Professionals,”
- Online electronic remittance advice/electronic click on “Pharmacy Services.” Here you’ll find
funds transfer (ERA/EFT) enrollment form information on:
- The ability to update your office profile - Aetna Specialty Pharmacy ® medicine and support
services including medication ordering, shipping
- Information on automatic studies
and delivery
- The Office Manual for Health Care Professionals
- Our formulary
• Clinical Policy Bulletins — Go to aetna.com.
- Pharmacy Clinical Policy Bulletins
• Preventive services guidelines — Go to our secure
• Aetna BRCA Precertification Information Request
provider website at https://navinet.navimedix.com.
Form — To get the form:
After logging in, choose “Aetna Health Plan” under
“My Health Plans.” Then go to Support Center > - Visit the “Health Care Professionals” section at
Clinical Resources > Preventive Services Guidelines. aetna.com. Then go to Resources for Health
Care Professionals > Forms > Medical Precertification.
- Call us at 1-800-624-0756.
6Gynecologic programs,
policies and reimbursement
Primary and preventive In areas where radiology services are capitated, the
gynecologic services member should be referred to the capitated site
(HMO, Aetna Health Network OnlySM plans and associated with her PCP.
Aetna Health Network OptionSM plans) For capitated radiology centers in the area, members
should contact their PCP or call the number on their
Direct-access/prior authorization policies
Aetna member ID card.
Our direct-access obstetrics and gynecology policy
covers services provided by a member’s obstetrician/
Automatic studies for gynecologic services
gynecologist (Ob/Gyn) without a referral from her primary
(HMO, Aetna Health Network Only plans and
care physician (PCP). A woman may also elect to have her
Aetna Health Network Option plans)
PCP perform her annual primary health care exam.
Automatic studies are services for which we pay
The Ob/Gyn should tell the member’s PCP about the
providers when the services are performed in the
services and treatment plan developed as a result of any
specialist’s office, regardless of whether the procedure
direct-access visits.
itself was specifically indicated on the referral.
In some areas, the Ob/Gyn may function as the
In general, these are procedures that are critical to the
member’s PCP and may refer the member to any
evaluation of the problem that led to the referral to
participating provider, including specialists, for any
the specialist.
covered, medically necessary services. For more
information, call us at 1-800-624-0756. Inclusion of a study on the automatic studies list doesn’t
guarantee payment. Rather, we’ll pay according to our
Billing standard processing guidelines.
The annual gynecologic primary and preventive visit
should be billed using the E&M codes for preventive To see a list of automatic studies for Ob/Gyns, go to
visits (99384 – 99387 and 99394 – 99397). https://navinet.navimedix.com.
All other visits should be coded using standard After logging in, select “Aetna Health Plan” under
E&M codes. “Plan Central,” then “Referrals” and “Automatic Studies
by Specialty.”
Your office should collect the appropriate copayment
from the member for these services. Refer to the Cervical cancer screening services
member’s ID card for copayment information.
Human papillomavirus (HPV) DNA screening
Radiology services We cover HPV DNA screening with either conventional
(HMO, Aetna Health Network Only plans and Pap smears or liquid-based cytology for primary cervical
Aetna Health Network Option plans) cancer screening of women ages 30 and older, when not
otherwise excluded by the member’s benefits plan.
Gynecology ultrasounds (for example, CPT codes 76830,
Women who receive negative results on both tests
76831, 76856 and 76857) may be performed in the
should be rescreened no more frequently than every
Ob/Gyn office without a referral or prior authorization
three years. This policy is consistent with guidelines
and are reimbursed on a fee-for-service basis.
from the American Congress of Obstetricians and
If the Ob/Gyn doesn’t provide office-based gynecology Gynecologists (ACOG) (2014).
ultrasounds, members should be referred to a
HPV DNA testing in women younger than age 30
participating radiology center with a valid
isn’t a covered benefit for primary cervical cancer
physician’s order.
screening. Again, this policy is consistent with ACOG
guidelines (2014).
7For more information, refer to Clinical Policy Bulletin For more information about the Breast Health Education
#0443. See our Clinical Policy Bulletins at aetna.com. Center, call 1-888-322-8742 from 8:00 a.m. to
Or find them on our secure provider website at 4:30 p.m. ET.
https://navinet.navimedix.com.
BRCA: genetic testing for breast and
Breast health
ovarian cancer
(all products)
(all products)
Referral policies Confidential molecular susceptibility testing for breast
Members have direct access to gynecologists who, and/or ovarian cancer (BRCA testing) is covered for
in addition to providing routine care, may authorize members who meet medical appropriateness criteria.
referrals for specialty care for related services. All BRCA testing must be precertified.
Gynecologists may refer members for consultations
(which include automatic studies) to the following For more information, refer to Clinical Policy Bulletin
specialties without a primary care physician #0227. Access our Clinical Policy Bulletins on our public
(PCP) referral: website at aetna.com. Or find them on our secure
provider website at https://navinet.navimedix.com.
• Breast surgery
We may also cover BRCA testing for non-Aetna members
• General surgery
when the information is needed to adequately assess
• Gynecologic oncology risk in the Aetna member and the non-member doesn’t
• Oncology have other coverage for this testing. Such coverage
• Urology requires prior authorization and is subject to the terms
of the subscriber’s benefits plan.
• Urogynecology
Mammography How to get BRCA testing approval for a member
Members have direct access for mammography services According to our Clinical Policy Bulletin #0227, all BRCA
at contracted radiology facilities. A referral isn’t testing must be precertified. We have a national network
necessary. For the provider to be reimbursed properly, of contracted providers that offer BRCA services. They
the member must present a valid physician’s order to a also offer a support network of genetic counselors who
participating radiology facility.* In areas with capitated are experts in inherited cancers. And they can help you
radiology arrangements, you should send members to select the right BRCA test. You’ll find these providers
the capitated site associated with their PCP. listed in our online directory at aetna.com.
To get approval for BRCA testing:
Breast cancer
Our Breast Health Education Center (available to HMO, 1. Complete our BRCA Precertification Information
Aetna Health Network Only and Aetna Health Network Request Form and fax it to us at 860-975-9126 for
Option plan members only) identifies members who review and approval.** You’ll find the form at
have been newly diagnosed with breast cancer within aetna.com > Health Care Professionals > Resources
the prior year and offers services to help them make for Health Care Professionals > Forms > Medical
informed choices about their treatment and recovery. Precertification. A list of our contracted providers is
Members can fill out a breast survey on their secure on the form.
member website to be referred to the center. Members
2. Fill out the contracted provider’s testing request form.
participating in the program may get:
To get the form, contact the provider.
• Personalized nurse care coordination
• Education about breast cancer
*Members with HMO-based plans in Alaska, Florida and Louisiana may require referrals for all radiology services
provided in hospital-based radiology settings. Mammography services (CPT codes 77061, 77062, 77063, 77065,
77066, 77067) may be performed in an Ob/Gyn office without a referral or prior authorization and be reimbursed
on a fee-for-service basis.
**Completion of an Aetna BRCA Precertification Information Request Form doesn’t guarantee payment.
Payment of covered benefits is subject to the provider’s contract, the member’s eligibility on the dates
of services rendered and specific provisions of the member’s health benefits plan.
83. If we approve testing, send our BRCA Precertification Capitated lab services for women’s
Information Request Form, the contracted provider’s health services
testing request form and the member’s specimen to (HMO, Aetna Health Network Only plans
the contracted provider. and Aetna Health Network Option plans)
4. There is an “Other” category on our BRCA Refer Aetna members to our network lab providers,
Precertification Information Request Form. This is like Quest Diagnostics, for covered services.
for women who don’t meet any criteria listed but
or whom it’s been determined (through both If you refer an Aetna member to an out-of-network lab,
independent formal genetic counseling and you must tell them you’re doing so and document the
quantitative risk tool assessment) to have at least a out-of-network referral. They must understand and
10 percent pretest probability of carrying a BRCA1 accept the possibly higher costs.
or BRCA2 mutation. For this category only, fax Covered lab studies include but aren’t limited to:
a three-generation pedigree and formal genetic
counseling and quantitative risk assessment • Beta hCG
results directly to us at 860-975-9126. • Glucose screening
• Prenatal panel
For more information, leave a message for us at
1-877-794-8720. We’ll call you back as soon as possible. • Serum analyte tests for aneuploidy screening in
pregnancy (see Clinical Policy Bulletin #0464)
Genetic counseling • Cell-free DNA testing (see Clinical Policy Bulletin #0464)
• Cytogenetic studies
Face-to-face and telephonic genetic cancer counseling
are available. These services are available without a • Cystic fibrosis carrier testing (see Clinical Policy
referral from the member’s PCP. Bulletin #0140)
• Basic infertility screening labs (see Clinical Policy
For a list of our contracted genetic counseling providers,
Bulletin #0327)
including our telephonic provider, InformedDNA, see our
online provider directory. Just go to the “Health Care • Sexually transmitted diseases (see Clinical Policy
Professionals” section at aetna.com. Then click on Bulletin #0433)
Helpful Links > Online Provider Directory. If you want • Cervical cancer screening, cytology and
InformedDNA, type the word “Genetics” into the Search HPV testing
box. Enter a city or ZIP code. Click “Enter.” The first listing You can see our Clinical Policy Bulletins on our public
will be “Genetic Conditions.” Click on it. website at aetna.com. Or find them on our secure
For more information about genetic cancer counseling provider website at https://navinet.navimedix.com.
through InformedDNA, call 1-800-975-4819 or go to
informeddna.com. HPV DNA testing
Members affiliated with IPAs must get approval through Routine cervical cancer screening isn’t recommended
their IPA prior to using telephonic genetic counseling. until after age 21. When not otherwise excluded by the
member’s benefits plan, we cover primary HPV DNA
Contraception screening with either conventional Pap smears or
(HMO, Aetna Health Network Only plans liquid-based cytology for primary cervical cancer
and Aetna Health Network Option plans) screening of women ages 30 and older.
To determine coverage, call us at 1-800-624-0756. ACOG recommends that women over age 30 who
have both a normal Pap smear and no evidence of
HPV infection be screened for cervical cancer no more
frequently than every three years. Our clinical policy
or cervical cancer screening coverage is consistent
with these recommendations.
9HPV testing is covered as a reflex or triage test that The vaccine is a series of three shots for women
follows a Pap smear laboratory result of atypical 13 to 26 years of age, if not previously vaccinated at
squamous cells of undetermined significance in women 11 or 12 years of age.
of any age, including women younger than 30 years of
For more information, see Clinical Policy Bulletin #0443.
age. It may also be covered as a follow-up when there
You can access our Clinical Policy Bulletins on our public
are abnormal histologic results, consistent with the
website at aetna.com. Or find them on our secure
guidelines of the American Society for Colposcopy and
provider website at https://navinet.navimedix.com.
Cervical Pathology.
For more information, see Clinical Policy Bulletin #0443. Infertility program
You can see our Clinical Policy Bulletins at aetna.com.
Or find them on our secure provider website at Our National Infertility Unit helps eligible members
https://navinet.navimedix.com. coordinate covered treatment-level infertility and
infertility-related genetic testing (preimplantation
More information on cervical cancer screening genetic testing) services and provides them with
recommendations is available through the information and guidance. The program is staffed by
following websites*: registered nurses, licensed practical nurses and
infertility coordinators with expertise in infertility.
• American Cancer Society
cancer.org To determine a member’s eligibility, call the phone
• American Congress of Obstetricians and Gynecologists number listed on the member’s ID card.
acog.org
Members who wish to access infertility benefits offered
• American Society for Colposcopy and under their plan should call us at 1-800-575-5999.
Cervical Pathology We’re here from 8 a.m. to 5 p.m. ET (7 a.m. to 3 p.m. PT).
asccp.org
Coverage may vary due to state mandates requiring
infertility coverage and optional infertility riders
HPV vaccine available to employer groups with over 500 members.
We consider a quadrivalent HPV (types 6, 11, 16, 18)
For more information, including the registration
recombinant vaccine for cervical cancer a medically
form, go to the “Individuals & Families” section on
necessary preventive service for males and females
aetna.com. Then under “Information &
from 9 to 26 years of age.
Resources,” select “Women’s Health,” then click
“Learn more about infertility and its treatment.”
*Inclusion of these organizations and websites does not constitute an endorsement by Aetna of the
organizations nor their websites, and Aetna has no responsibility for the accuracy or currency of the content
of the websites.
10Beginning Right® maternity program
The goal of the Beginning Right maternity program is to Second trimester educational mailing
help members and providers achieve a healthy term Members get an educational mailing at 14 weeks’
delivery. It provides educational materials, and eligible gestation. This includes information about:
members receive case management throughout
their pregnancies. • Signs and symptoms of preterm labor
• High-risk pregnancy conditions
Member eligibility
Third trimester educational mailing
The Beginning Right program is available to most During their eight month, members get an educational
pregnant HMO-based plan members. Members of other packet. It includes information about the timing of
health benefits plans may be eligible to participate in the delivery and postpartum concerns:
program, depending on the individual employer-
• Waiting for Baby educational video at aetna.com/
sponsored plan. To see if a member is eligible for the
individuals-families/womens-health/pregnancy
program, call the number listed on the member’s
information-video.html
Aetna card.
• Information on the need for a postpartum visit four to
Member enrollment six weeks after delivery
• Brochure with helpful guidance for the mother and
To begin the program enrollment process or learn more
health tips for the baby
about the program, call us at 1-800-272-3531. Members
• Immunization schedule for healthy infants and
can also enroll via their member website. Once on the
children, based on guidelines from the Centers for
site, members should go to “Information & Resources”
Disease Control and Prevention (CDC) Advisory
then “Women’s Health.”
Committee on Immunization Practices
Program content • Procedures for adding a newborn to the member’s
health plan coverage
We’ll provide members with educational materials
throughout their pregnancy, including:
Welcome packet
After enrolling in the program, the membes get a
welcome packet that includes information about:
• Normal pregnancies
• Prenatal care
• Dental health
• High-risk pregnancy conditions
• Postdelivery care
• Postpartum depression
• Newborn care
11Pregnancy risk survey members identify preterm labor. Program components
may include one or more of these:
To enroll in the program, members must first complete a
pregnancy risk survey. This survey identifies risk factors • Education about the signs and symptoms of preterm
that may complicate a member’s pregnancy and for labor by trained obstetric nurses
which we provide additional services. • A home nurse visit (if available in her area) to review
We assign a nurse case manager to members with the symptoms of preterm labor and teach how to
certain high risk factors. The extent of time and palpate for contractions
involvement of the case manager depends on the risk • Continued care coordination by a Beginning Right
factor and the chronicity of the problem. program nurse case manager if preterm labor occurs
We provide case management for these risk factors: Beginning Right follow-up of members requiring
17 alpha-hydroxyprogesterone caproate (17P) for
• Pregnancy-induced hypertension or chronic a previous preterm birth
hypertension
Members who self-inject with 17P will be contacted
• Type 1 or 2 diabetes or gestational diabetes weekly by a Beginning Right nurse case manager during
• Hyperemesis (during acute treatment phase only) the first month of treatment and monthly until delivery.
• Women at risk for preterm birth, including those with They’ll contact all others the first week to verify start
a prior preterm delivery, women in the extremes of date and then monthly until delivery.
reproductive age (younger than 19 and older than
40 years) and African American women African American preterm labor
• Active preterm labor education program
• Multiple gestation Preterm birth rates were nearly 48 percent higher
• Smoking among black women compared to white women.1
• History of postpartum depression or depression
For this reason, we developed a comprehensive preterm
• Others not listed labor education and support program targeting
pregnant African American members.
Case management of high-risk
pregnancy activities The primary goals of the program are to:
Nurses provide education and outreach focused on the • Improve member and physician awareness of the
high-risk factors we identify. Activities may include: increased risk of premature birth for African
• Collaboration with obstetric providers to American women
coordinate care • Implement member education programs that increase
• Review of signs and symptoms of preterm labor during member knowledge of how and when to best access
each member contact care and participate in treatment decisions
• Specialized education and medically indicated home Program components offered to all self-identified
care services, including: African American pregnant members include:
- Preterm labor education program • Educational information on preterm birth
- Smoke-Free Moms-to-Be® smoking
• Telephone outreach at 24 weeks’ gestation by a
cessation program
clinician nurse to offer enrollment in the preterm labor
Preterm labor education program education program
• A home nurse visit, if available in the member’s area, to
Pregnant members identified through the pregnancy
review the signs and symptoms of premature labor and
risk survey as being at risk for preterm labor (or whose
instructions on how to self-palpate for contractions
physician requests certain services) are offered
• Periodic calls from Beginning Right nurse case
enrollment in the preterm labor education program.
managers to review signs and symptoms of
This is if their plan offers home health care benefits.
preterm labor
The program provides educational instruction to help
March of Dimes, 2016 Premature Birth Report Cards. Preterm birth increases in the U.S. for the first time
1
in eight years. September 20, 2017.
12Smoke-Free Moms-to-Be smoking postpartum outreach is completed three to five
cessation program weeks postdelivery and then again three to four
months postdelivery.
If a pregnant member indicates on the pregnancy risk
survey that she smokes, we’ll offer her the chance to We offer women who screen as positive for antenatal or
participate in Smoke-Free Moms-to-Be, our nicotine-free postpartum depression access to an appropriate Aetna
smoking cessation program. This program includes: Behavioral Health provider. Or we refer to their obstetric
care provider if they don’t have behavioral health
• An educational brochure benefits. Where applicable, we provide access to
• A cigarette substitute Aetna Behavioral Health med/psych case managers.
• Contact with a Beginning Right nurse case manager Other behavioral health programs or providers are
throughout the pregnancy also available.
Pregnancy and postpartum Diabetic case management for
depression screening pregnant members
The Beginning Right maternity program, working with Beginning Right nurse case managers:
Aetna Behavioral Health, has developed a pregnancy
• Work with the obstetric care provider to coordinate
and postpartum depression screening program.
diabetic education and nutritional counseling
This program aims to reduce the severity, duration and • Consult with a perinatologist or endocrinologist for
impact of depression during and after pregnancy. The diabetes management
program uses a depression screening tool to help
• Generate any prior authorizations that the member’s
identify members who may be at risk for depression.
plan requires.
The antenatal depression screening is included on all
pregnancy risk surveys performed by phone or during
the first phone contact with members who complete the
pregnancy risk survey on their member website at
aetna.com. The postpartum screening is done for
all members who qualify for these calls. The first
13Other important notes While there may be times during which appointment
availability may not meet these standards, an office
Getting obstetric care must generally be able to keep this degree of access. In
Members with a positive pregnancy test (either home group practices, members should be offered the option
urine pregnancy test or blood test) can get obstetric of seeing another provider in the office if an individual
care directly, without written prior authorization from physician can’t meet the above standards.
a PCP.
If, for any reason, your office won’t be able to offer this
Though precertification of delivery isn’t required, we ask level of appointment availability (other than the
obstetric care providers to call the Beginning Right emergency standard) for more than four consecutive
maternity program at 1-800-272-3531 to begin the weeks, call us at 1-800-624-0756 as soon as possible.
program enrollment process. To enroll in the program,
The Beginning Right maternity program is subject to
members must complete the pregnancy risk survey.
change without notice. Certain features may not apply
Please tell members that they must call the
in all cases.
Beginning Right maternity program or log in to their
member website at aetna.com to take the survey and Not all programs are available to all members. Call
complete the enrollment process. the number listed on the member’s ID card to find
out if a particular patient is eligible to participate in
Enrollment in the program will entitle all eligible
this program.
members to get:
• Educational materials in English or Spanish
• The opportunity to complete a pregnancy risk survey
• Nurse case management if they are identified by the Call the Beginning Right
pregnancy risk survey to be at risk for certain medical maternity program at
conditions, such as preterm birth, chronic
hypertension or gestational diabetes 1-800-272-3531 to:
• Access to our smoking cessation program
Members who enroll in the Beginning Right program • Register eligible members
before 16 weeks’ gestation receive a gift.
• Access case management
Prenatal care access standards
Appointments for routine obstetric visits and urgent
services
conditions must be available to members within • Learn more about
reasonable time frames.
the program
We’ve adopted the following standards for prenatal care
appointment availability:
First visit for Within three weeks in the
obstetric care first trimester; within two
weeks in the second or third
trimesters
Urgent visits Within 24 hours
Postpartum visit Four to six weeks
after delivery
14Obstetric policies and reimbursement
Global obstetric fee Reimbursement for obstetric ultrasounds remains on a
(HMO, Aetna Health Network Only plans and fee-for-service basis for members enrolled in indemnity
and preferred provider organization (PPO)-based plans.
Aetna Health Network Option plans)
Note: We don’t require prior authorization from the
Services reimbursed outside of the global obstetric
Beginning Right maternity program for a pregnant
fee include:
member’s routine laboratory studies if done at the
Inpatient visits provided for the below are considered capitated laboratory associated with the member’s PCP.
part of the global obstetric fee and are not subject to Or if there’s no capitated laboratory, at any participating
payment on a fee-for-service basis: laboratory in the network.
• The day before delivery The national laboratories provide a full range of
• The three postpartum days for vaginal delivery laboratory services, including cystic fibrosis screening,
cytogenic studies and other genetic services.
• The five postpartum days for cesarean delivery
Amniocentesis, chorionic villus sampling and biophysical
profiles are reimbursed on a fee-for-service basis.
Office visits and ultrasounds performed by the obstetric
care provider on members presumed to be pregnant
(based on a previous pregnancy test) who are found not
to be pregnant are reimbursed on a fee-for service
basis. Submit a claim for the office visit using the correct
ICD code for the unconfirmed pregnancy.
15Perinatology services
On the next two pages, you’ll find some of the more A referral from the Ob/Gyn or PCP to the perinatologist
frequently used services that a perinatologist performs. is required for: Aetna SelectSM EPO plans, Elect Choice®
These services don’t require prior authorization. But plans, HMO plans, Managed Choice® POS and Quality
they may require evidence of medical appropriateness Point-of-Service® plans. Referrals can be done
as a condition of reimbursement. through our secure provider website at
https://navinet.navimedix.com.
Procedure CPT codes ICD codes considered medically Comments
appropriate
Consultations: 99241 – 99245 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93,
Office visits: 99201 – 99205 and 99211 V28.2 = Z36, V28.4 = Z36
– 99215
Routine fetal ultrasounds: 76801, 76802, See Clinical Policy Bulletin #0199
76805, 76810, 76815, 76816, 76817, for ICD codes.
NT76813 and NT76814
Detailed fetal ultrasounds: 76811, 76812 See Clinical Policy Bulletin #0199 One detailed fetal ultrasound (CPT code
for ICD codes. 76811) per member, per pregnancy, per
practice is covered.
Any follow-up of 76811 should be billed
with another CPT code.
Genetic counseling: 99243 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93,
V28.2 = Z36, V28.4 = Z36
Nuchal translucency (NT) testing: See Clinical Policy Bulletins #0199 ACOG recommends the following for
and #0464 for ICD codes. NT screening:
• 76813: Nuchal translucency testing
• 76814: Nuchal translucency testing each 1. Appropriate ultrasound training and
additional gestation ongoing quality monitoring programs
• 84704: hCG free Beta are in place.
• 84163: PAPP A 2. Sufficient information and resources
• 82105: AFP are available to provide comprehensive
• 84702: hCG quantitative counseling to women regarding the
different screening options and
limitations of these tests.
3. Access to an appropriate diagnostic
test is available where screening test
results are positive.
Cell-free DNA testing: See Clinical Policy Bulletin #0464
81420 for ICD codes.
Amniocentesis: 59000 640.00 - 676-94 = O20.0 - O92.70 Amniocentesis based on patient demand
V23 - V23.9 = O09.0 - O09.93, V28.2 = is covered.
Ultrasound guidance for amniocentesis: Z36, V28.4 = Z36
76946
1617
Procedure CPT codes ICD codes considered medically Comments
appropriate
Chorionic villi sampling (CVS): 59015 640.00 - 676-94 = O20.0 - O92.70 CVS based on patient demand
V23 - V23.9 = O09.0 - O09.93, V28.2 = is covered.
CVS with ultrasound guidance: 76945 Z36, V28.4 = Z36
NST: 59025 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93, V28.2 =
Z36, V28.4 = Z36
Biophysical profile (BPP): 76818 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93, V28.2 =
Z36, V28.4 = Z36
BPP without NST: 76819 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93, V28.2 =
Z36, V28.4 = Z36
Fetal echocardiograms: 76825, 76826, See Clinical Policy Bulletin #0106 Services must meet medical
76827, 76828, 93325 for ICD codes. appropriateness edits described in
Clinical Policy Bulletin #0106.
Fetal umbilical artery Doppler: 76820 See Clinical Policy Bulletin #0106 Services must meet medical
for ICD codes. appropriateness edits described in
Clinical Policy Bulletin #0106.
Middle cerebral artery Doppler: 76821 See Clinical Policy Bulletin #0106 Services must meet medical
for ICD codes. appropriateness edits described in
Clinical Policy Bulletin #0106.
Percutaneous umbilical blood sampling 640.00 - 676-94 = O20.0 - O92.70
(PUBS): 59012 V23 - V23.9 = O09.0 - O09.93, V28.2 =
Z36, V28.4 = Z36
Fetal transfusion: 36460 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93, V28.2 =
Z36, V28.4 = Z36
External cephalic version: 59412 640.00 - 676-94 = O20.0 - O92.70
V23 - V23.9 = O09.0 - O09.93, V28.2 =
Z36, V28.4 = Z36
18Reproductive genetic counseling Postpartum visit
For a list of our contracted genetic counseling providers, ACOG recommends that women visit their obstetric care
including our telephonic provider, InformedDNA, see our provider approximately four to six weeks after delivery.2
online provider directory. Just go to the “Health Care The visit should include:
Professionals” section at aetna.com. Then click
• An interval history and physical exam to evaluate the
“Online Provider Directory.”
patient’s current status as well as her adaptation to
the newborn
Rh immune globulin policy
• Specific questions including those related to
Antenatal Rh immune globulin is available to Rh negative postpartum depression about breastfeeding
members by having blood drawn: • An evaluation of weight, blood pressure, breasts
• In the PCP’s office and sent to a participating and abdomen
contracted or capitated laboratory. The obstetric • A pelvic examination and Pap smear, if appropriate
care provider may then provide and administer Rh • Conception counseling and management
immune globulin either before or after the results of
Payment for the postpartum visit is included in the
the lab test come back, as determined by the physician.
global obstetric reimbursement fee.
• In the obstetric care provider’s office and sent
to a participating contracted or capitated laboratory.
Non-emergency, non-obstetric
The RhoGAM can be obtained through our
medical care
specialty pharmacy network. Just visit
aetnaspecialtypharmacy.com. The Rh immune If a member has a non-emergency, non-obstetric
globulin can be administered by the medical need (for example, rashes, pneumonia, etc.),
obstetric care provider or PCP. she should be directed either to her PCP (in plans
• At the hospital laboratory. The Rh immune globulin that require the member to select a PCP) or to the
may be administered in the outpatient department appropriate participating physician (in other plans)
of the hospital. No referral is needed for either the for care and management.
lab work or the Rh immune globulin administration These services aren’t reimbursed on a fee-for-service
at the hospital. basis to the member’s obstetric care provider. Rather,
the obstetric care provider should notify the PCP or
Flu vaccination
appropriate participating physician of the member’s
The CDC recommends that healthy pregnant women medical problem and discuss any obstetric implications
who are in their second or third trimester during the flu involved with the treatment of this problem. The PCP/
season get the flu vaccine. Also, women at any stage of physician will then determine if any further referrals to
pregnancy with certain chronic medical conditions, such specialists are necessary.
as asthma, diabetes mellitus or heart disease, should get
In some areas, the obstetric care provider may function
the vaccination.
as the member’s PCP and may refer the member to any
This vaccine is covered when administered to a participating provider for any covered, medically
pregnant woman. Physicians are reimbursed necessary services. To find out the details in your
separately for this immunization. For more information, specific area, call us at 1-800-624-0756.
visit cdc.gov.
2
American College of Obstetricians and Gynecologists, Committee Opinion No. 666.
Optimizing Postpartum Care. June 2016. 19Spontaneous abortions - 59514: cesarean delivery only
- 59515: cesarean delivery and postpartum care
An Ob/Gyn who provides care for a member with an
incomplete, missed or completed spontaneous abortion - 59614: vaginal birth after cesarean delivery and
(CPT codes 59812, 59820, 59821 and 59830) may be postpartum care
reimbursed for the office visit, as well as for related - 59612: vaginal birth after cesarean delivery only
procedures, regardless of whether the member is
formally enrolled for obstetric care with the provider. High-risk pregnancy management
This acute care isn’t included in the global obstetric fee. enhancement
If a pregnancy results in a spontaneous abortion, the We pay an additional fee to the obstetric care provider
surgical procedure, necessary ultrasounds and prenatal for managing a high-risk pregnancy. This applies to all
care are paid at the Aetna Market Fee Schedule rate — products when the following are true:
regardless of whether or not there is a referral on file.
• The member is enrolled in the Beginning Right
All non-elective abortions are covered unless specifically
maternity program, if available.
excluded under the member’s plan.
• Risk factors are identified.
You should use office visit E&M codes when billing for • There’s an increase in the intensity and/or frequency
these services, as well as the ICD code indicating a of care throughout the pregnancy.
spontaneous abortion. Any ultrasounds done during the
• Modifier 22 is added to the global obstetric fee claim.
pregnancy that otherwise would have been included in
the global obstetric fee should be billed with the ICD When the obstetric care provider’s bill is submitted for
code indicating a spontaneous abortion. global maternity care reimbursement, the request for
enhanced reimbursement must include clinical
The global fee for maternity care doesn’t apply when
documentation of the additional care provided during
there’s a pregnancy loss before 20 weeks. If a member
the pregnancy. This should include the obstetric care
is enrolled as an obstetric patient in the obstetric
provider’s clinical summary and prenatal flow sheet,
care provider’s practice and loses her pregnancy
as appropriate.
spontaneously, she is responsible for only the single
copayment to her obstetric care provider paid at the Examples of diagnoses that qualify for the high-risk
first obstetric visit. Although we adjust payment to a enhancement include but aren’t limited to:
per-date-of-service payment of Aetna Market Fee
• Insulin-dependent diabetes
Schedule rates, only a single member copayment
is applied. • Chronic hypertension on anti-hypertensive medication
• Premature labor, managed throughout pregnancy
Instructions for billing portions of prenatal • Chronic medical conditions that require weekly
care and delivery evaluation for uteroplacental insufficiency
Physicians who provide total prenatal care and delivery • Obstetric or medical conditions requiring prolonged or
should bill CPT code 59400 for a vaginal delivery, 59514 repeated hospitalizations
for a cesarean delivery, and 59610 for a vaginal birth
Cell-free fetal nucleic acid screening
after cesarean delivery. Physicians who provide some
but not all of the prenatal care and delivery should bill We cover cell-free fetal nucleic acid screening for women
for the portion of prenatal care according to the at high risk for genetic chromosomal abnormalities in the
following CPT instructions: fetus. High-risk conditions include maternal age greater
than 35 at delivery, prior pregnancy with a chromosomal
• 59425: four to six prenatal visits
abnormality, abnormal fetal ultrasound or laboratory
• 59426: seven or more visits screening tests suggesting a chromosomal abnormality.
• Use standard E&M codes for fewer than four (See Clinical Policy Bulletin #0464.)
prenatal visits
- 59409: vaginal delivery only
- 59410: vaginal delivery and postpartum care
20First and second trimester non-invasive Credentialing requirements for fetal
screening to provide individual risk aneuploidy screening involving nuchal
assessment for fetal aneuploidy translucency (NT) measurement
The following screenings for fetal aneuploidy are To help ensure the accuracy of the NT screening, the
covered medical services for all pregnant women. ultrasonographer performing the NT measurement and
(See Clinical Policy Bulletin #0282.) the sonologist interpreting the NT measurement must
• First trimester nuchal translucency (NT) measurement be credentialed. The credentialing process in the United
results combined with the results of first trimester States is the Nuchal Translucency Quality Review (NTQR)
serum analyte tests that include pregnancy-associated program. Numerous professional societies have
plasma protein A (PAPP-A) plus beta-human chorionic promoted NT credentialing, including ACOG, the Society
gonadotropin (hCG) or for Maternal-Fetal Medicine and the March of Dimes.
• Integrated, sequential or contingent screening: first Note that a large number of genetics laboratories,
trimester results (NT, PAPP-A and hCG) plus second including two Aetna-participating laboratories,
trimester quad (maternal serum alpha-fetoprotein Genzyme Genetics and Quest Diagnostics, require
[MSAFP], unconjugated estriol, inhibin A and hCG) evidence of credentialing of NT measurements to
screening or combine NT measurement and serum analyte values
• First trimester NT testing alone (without serum analyte and report results for Aetna members. You can find
screening) for multiple gestations or more information about the NTQR process and online
• Serum-integrated screening for pregnancies where registration at ntqr.org.
NT measurement isn’t available or can’t be obtained: You can also see our Clinical Policy Bulletins
first trimester (PAPP-A plus hCG) plus second trimester on our secure provider website at
quad (MSAFP, unconjugated estriol, inhibin A and hCG) https://navinet.navimedix.com.
screening or
• Second trimester serum analyte screening (see Clinical
Policy Bulletin #0464)
Preauthorization isn’t required for NT testing or the
laboratory studies.
21Other services covered for individual risk Intramuscular progesterone therapy is not an
assessment for fetal aneuploidy appropriate treatment for:
• Amniocentesis or CVS regardless of maternal age • Previous preterm birth due to a medical complication
(see Clinical Policy Bulletin #0358) or “indicated preterm delivery” (for example, PIH,
• Quad screening (maternal age plus alpha fetoprotein, diabetes, placenta previa)
estriol, total beta-hCG and dimeric inhibin A) in the • Gestational age at initiation of therapy is greater
second trimester for women of any age who don’t than 23 weeks’ gestation
undergo first trimester testing (see Clinical Policy • Member is in active preterm labor and 17P is being
Bulletin #0464) used as a tocolytic
You can access our Clinical Policy Bulletins • Member is pregnant with twins
at aetna.com. Or find them on our • Member with cerclage in place
secure provider website at
https://navinet.navimedix.com. Process to get intramuscular progesterone
The drug 17P is a compounded drug and available only
Screening schemes that aren’t covered include:
through specialty pharmacies.
• First trimester serum testing without NT testing
• NT testing without serum testing Optional covered services to support members
requiring 17P
• Cell-free DNA testing in women at low risk of
fetal aneuploidy • Perinatology consult
• Home nurse visit for instruction in self-administration
Intramuscular progesterone therapy of an intramuscular injection
Pregnant women who experienced a previous • Preterm labor education program
spontaneous preterm birth may be appropriate for
intramuscular progesterone therapy (17 alpha
Home births
hydroxyprogesterone caproate, or 17P) in subsequent We consider planned deliveries at home and associated
pregnancies. Weekly intramuscular administration of services not medically appropriate. (See Clinical Policy
250 mg of 17P from 15 through 20 completed weeks’ Bulletin #0329.)
gestation and continued through 36 completed weeks of
pregnancy has been shown to decrease the recurrent Note: Provision of home births will be considered if
spontaneous preterm birth rate by up to 33 percent.3 mandated by state law.
Criteria for intramuscular progesterone therapy
• Previous spontaneous preterm birth at less than
37 weeks, including premature rupture of the
membranes, or “PROM”
• Gestational age at initiation of therapy is less than 23
weeks’ completed gestation
• Currently pregnant with a singleton pregnancy
3
American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 130.
Prediction and Prevention of Preterm Birth. October 2012 (reaffirmed 2016).
22Frequently asked questions
1. Can I be reimbursed for gynecological 8. How can an Aetna member access her
ultrasounds performed during a routine infertility benefits?
gynecological visit without obtaining a referral?
Most Aetna plans require precertification for infertility
Yes. Gynecological ultrasounds (CPT codes 76830, treatment level care. Once you have a plan for
76831, 76856 and 76857) are paid fee-for-service. infertility treatment using injectable medication,
artificial insemination or assisted reproductive
2. Does Aetna cover the HPV vaccine? technology procedures, use our Infertility Program
Patient Registration Form to register with our
Yes. We cover the HPV vaccine for covered female
National Infertility Unit. You’ll find the form at
members from 9 to 26 years of age. (See Clinical Policy
aetnainfertilitycare.com.
Bulletin #0726.)
Once you’ve completed the form, you or the member
3. Does Aetna have a support program for female can fax it to us at 860-607-7476. We’ll review the form
members diagnosed with breast cancer? and let the infertility specialist know if the member
meets the initial criteria to start using her infertility
Our Breast Health Education Center is available for treatment benefits. For more information, you or the
members newly diagnosed with breast cancer who member can call us at 1-800-575-5999. Except for
are in an HMO, Aetna Health Network Only or Aetna Thursdays, we’re here 8 a.m. to 5 p.m. ET (7 a.m. to
Health Network Option plan. 3 p.m. PT), Monday through Friday. On Thursdays,
we close at 4 p.m. on the East Coast only.
4. Does Aetna cover BRCA genetic testing?
Yes. We cover BRCA genetic testing for members who 9. Because Aetna no longer requires pregnancy
meet one or more of the clinical criteria described in precertification, is it necessary to notify you of
Clinical Policy Bulletin #0227. To learn more about our a member’s pregnancy?
BRCA Genetic Testing program, call 1-877-794-8720. No. But we do ask that you call the Beginning Right
maternity program at 1-800-272-3531 to begin the
5. How can I get approval for BRCA program enrollment process. The member must
genetic testing? complete the pregnancy risk survey to be considered
To get a copy of our BRCA Precertification Information for the program. We encourage you to inform the
Request Form, go to aetna.com. member that she must call the Beginning Right
maternity program at 1-800-272-3531 or log in to
You can also call us at 1-800-624-0756 for her member website at aetna.com to complete the
more details. program enrollment process.
6. Does Aetna cover genetic counseling? Enrollment in the program provides all eligible
members with:
Yes. We cover genetic counseling for members with
medical indications that support it. Face-to-face or • Educational mailings
phone counseling is available. See our online provider • Our pregnancy risk survey
directory at docfind.com for locations. • Nurse case management for members with
selected medical problems who are classified as
7. How can I find out what infertility benefits an high risk
Aetna member has? • Free gift when member enrolls by completing the
Call the number listed on the member’s ID card. pregnancy risk survey by 16 weeks of pregnancy
We can also tell you if the member has a specific
provider network.
2310. How will I be reimbursed if an Aetna member 12. Will I be reimbursed for prenatal lab work
miscarries after the first prenatal visit? performed in the office?
To be reimbursed for the visit and for any Yes. Lab studies (CPT codes 85013, 85018, 82947,
ultrasounds performed, submit the appropriate E&M 82948 and 82962) performed in the obstetric office
and ultrasound codes with the diagnosis indicating setting on pregnant members will be reimbursed
spontaneous abortion (ICD10 - O03.9). outside of the global obstetric fee when billed with
diagnosis codes V22-V22.2 = Z34.00 -Z33.1,
11. Will I be reimbursed, in addition to the global V27-V39.2 = Z37.0-Z38.1 and 640 - 677 =
obstetric fee, when I visit an Aetna member O20.0 - O94.
during an antepartum inpatient stay? For other lab work, use our in-network labs.
Yes. You’ll be reimbursed fee-for-service for each You’ll find these providers in our online directory
visit (CPT codes 99217 through 99239) you make to a at aetna.com. Or refer to this list:
member during an antepartum inpatient stay when aetna.com/docfind/cms/assets/pdf/
billed with diagnosis codes V22-V22.2 = Z34.00 DocFind_PDF_Lab_List9_10.pdf.
-Z33.1, V27-V39.2 = Z37.0-Z38.1 and 640 - 677 =
O20.0 - O94.
24You can also read
