Aetna OfficeLink Updates Mid-Atlantic Region

Quality health plans & benefits

Healthier living

Financial well-being

Intelligent solutions

June 2013 • Volume 10, Issue 2

Mid-America Region

Inside this issue

Policy and Coding

Updates 2-4

 

Learning Opportunities 7

Electronic Transactions 8

 

Options to reach us

•Select Health Care

Professionals

•Select “Medical Professionals

Or call our Provider Service Center:

• 1-800-624-0756 for HMO-based

benetsplans,Medicare

Advantage plans and WA Primary

Choice plan

• 1-888-MDAetna

(1-888-632-3862)

for all other plans

48.22.808.1-Q2-MA (6/13)

www.aetna.com

Aetna

OfficeLink Updates

What you need to know about contracting and reimbursement

We are looking at ICD-10’s effect on provider

contracts and clinical operations. The purpose of

the ICD-10 conversion isn’t to change

reimbursement.However,theincreased

specificity of the code set may more accurately

show patient status and/or care.

ICD-based contract provisions

If a contract includes an ICD-9 diagnosis and/or

procedurecodeasacarve-out,we’llrecontract

theseprovisionsbeforeOctober1,2014.And,we

may start as early as mid-2013.

We won’t update contracts to use ICD-10

codes. Our current contract terms support the

requirement that providers bill with Health

Insurance Portability and Accountability Act

(HIPAA)-compliantcodesets,asoftheir

respective HIPAA compliance dates. For ICD-10

codes,thisisOctober1,2014.Thereisnoneed

to change the general wording in our contracts.

ICD-10

We understand that some provider offices may

have been asked by LabCorp to sign laboratory

services agreements. LabCorp and its affiliates

are not contracted with Aetna and are

nonparticipating. The only exceptions are

DynacareNorthwestandLitholink,bothin

Washington state.

As a reminder:

•Onlyuseparlabs.Referralstononparlabs

mean that your patients will have to pay more

out of pocket. You can help them save money

by referring them to in-network labs.

•InCalifornia,thisinformationappliestoyour

non-HMO Aetna patients. Continue to direct

yourAetnaHMOpatients,whoareenrolled

withyouraffiliatedIPA,toappropriatelab

vendors in accordance with your IPA’s

administrative guidelines.

•Foralistofin-networklabs,visitour

DocFind

online provider directory.

Select the “Advanced Search” tab.

Under“Searchfor,”select“Labs-including

QuestDiagnostics.”Under“Type,”select

“National Lab Listing.”

Reminder: Only use participating laboratories

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Policy and Coding Updates

Clinical payment, coding and policy changes

Weregularlyadjustourclinical,paymentandcodingpolicypositionsaspartofourongoingpolicyreviewprocesses.Indevelopingour

policies,wemayconsultwithexternalprofessionalorganizations,medicalsocietiesandtheindependentPhysicianAdvisoryBoard,

which provides advice to us on issues of importance to physicians. The chart below outlines coding and policy changes:

Procedure Implementation

date

What’s changed

Relatedservices Reminder We will deny services related to an ineligible procedure or service.

National Drug Code (NDC)

billing

Reminder

The NDC submitted must be the actual NDC number noted on the medication

package or container. The appropriate HCPCS code and units are also required. For

unclassified J codes and other HCPCS/CPT codes that do not describe the dosage

perHCPCS/CPTcodeunit,includetheNDCcode,NDCunitsandHIPAAstandard

NDC unit of measure qualifier. The NDC units and NDC units qualifier must

represent the dosage for the charge.

Formoreinformation,refertotheNDCBillingGuideonthePharmacysectionof

our

secure provider website.

Using in-network providers

maximizespatients’benefits

Reminder

WhencaringforyourAetnapatients,remembertouseorreferthemto

participating providers. Doing so will ensure the following:

•Theygettheappropriatelevelofbenefitsavailabletothem.

•Theirclaimswon’tbedeniedduetonothavingaprecertificationonfile.

In the rare situation where a certain medical service is not available in our network

andyoumustuseorreferanAetnapatienttoanonparticipatingprovider,besure

to follow the precertification process. For more details on our precertification

process,gotoour

secure provider websiteandselect“Transactions,”then

“Precertification.”

Pap smears Reminder Effective4/23/2013,AetnaupdateditsCervicalCancerScreeningandDiagnosis

clinical policy to only allow Pap smear screenings for female members who have

reached age 21.

Pap smear screenings are considered experimental and investigational for a woman

under age 21 because it was found the practice causes more medical harm than

benefit. Aetna’s policy change aligns with those of the U.S. Preventive Services Task

Force,AmericanCollegeofGynecologists(ACOG),andotherleadingmedical

societies that recently raised their guidelines to age 21.

Exception: Aetna continues to allow pap smear screenings for females under age 21

thathaveadiagnosisofcervicaldysplasia,cervicalcancer,DESexposure,HIV

infection,orareclassifiedasimmuno-compromisedwomen.

Note:ThispolicychangedoesnotapplytomembersenrolledinMedicareproducts,

or fully-insured members in states with age-related pap smear screening

mandates,includingAK,AR,DE,MA,ME,NV,NJ,NY,OR,PA,RI,TX,VAandWY.

Drug frequency Reminder Our max imu m dos ag e lim it for m edi c at ion s (inc lu din g inje ctab le dr ug s) i s ba s ed o n

FDA-approved guidelines and/or the manufacturers’ recommended frequency.

Unlisted radiology codes

billed with mammograms

Reminder We don’t consider the generation or analysis of automated data as eligible for

payment. The manipulation of data previously obtained from the performance of a

test or procedure is considered incidental and integral to the test or procedure that

was performed.

JUNE 2013

Procedure Implementation

date

What’s changed

Durable medical equipment

modifiers:

•ModifierNU(NewDME

purchase)

•ModifierRR(Rental)

Reminder Durable medical equipment items eligible for purchase or rental must be submitted

with a modifier designating whether the item billed is a rental or purchase.

We will deny claims submitted without the appropriate modifier.

Durable medical equipment

supplies and accessories

Reminder

RefertothefollowingClinical Policy Bulletins(CPBs)todeterminethemedically

necessary quantities for the related DME supplies and accessories:

•Positiveairwaypressuredevices–CPB#0004–ObstructiveSleepApneainAdults

•Transcutaneouselectricalnervestimulators(TENS)–CPB#0011–Electrical

Stimulation for Pain

•Nebulizers–CPB#0065-Nebulizers

*Globalsurgicaldaysfor

procedures with CMS global

value of YYY

9/1/2013

Effectivefordatesofserviceonorafter9/1/2013,globalsurgeryperiodswillbe

applied to codes listed on the CMS physician fee schedule with a value of YYY.

RefertoClaimPaymentPolicy,EvaluationandManagement(E&M)Servicesduring

theGlobalSurgeryPeriodonour

secure provider website.

* CCI outpatient code editor

(OCE) edits for OP facility

and ASCs

9/1/2013

Effectivefordatesofserviceonorafter9/1/2013,wewillapplyCMSCCIOCEedits

(Outpatient Code Editor) to claims for OP Facility and ASC (Ambulatory Surgery

Centers).Refertooursecure provider websiteandselectClaimPaymentPolicy,

CCI OCE edits for more information.

Precertification will not

override codes considered

“never effective”

9/1/2013

Precertification will not override the denial of codes considered never effective.

RefertotheCodeEditing,Clinical&PaymentPolicyCodeLookuponour

secure provider website to determine if a code is considered “never effective.”

High cost drug discounts and

rebates

9/1/2013 We will not pay the portion of services covered by a manufacturer's rebate. We will

pay the lesser of our negotiated rate or the cost of the covered service minus the

rebate and the provider will be responsible for obtaining the rebate from the

manufacturer.

Forexample,themanufacturerforthedrugZiv–Aflibercept(Zaltrap)haspublished

rebateinstructionsforproviders.Whenprovidersareentitledtothisrebate,our

covered services will be reduced by the rebate amount.

Special charges and

incremental nursing charges

9/1/2013

(excludes

Maryland and

Washington at

this time)

Aetna will no longer roll up special charges (revenue code 221-223) and

incremental nursing charges (230-239) into the room and board charges billed on

facility-based confinement claims for all products processed on the Strategic

platform.

ForallHMOandTraditionalplans(excludingMedicareAdvantage),wewillenforce

the existing inpatient private duty nursing payment policy for inpatient private duty

nursing services billed in conjunction with a confinement and add special charges

to the existing policy.

* Washington providers: This item is subject to regulatory review and separate notification.

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Proper mid-level practitioner billing requirements

We define mid-level practitioners as nurse

practitioners,physicianassistants,nurse

midwives and clinical nurse specialists/

registered nurses*.

Under our requirements and following the

Centers for Medicare and Medicaid

Services’ (CMS) “incident to” and “split/

sharedservices”guidelines,youmustbill

“incident to” or “split/shared” services

as follows:

•Submitclaimswiththesupervising

physician’s name as the servicing

provider. You should also use the

SA modifier.

For claims that are not “incident to” or

“split/shared services” you must list the

mid-level practitioner’s name as the

servicing provider when filing claims for

services they provide. We reserve the right

to take appropriate action for any violation

of policy.

Confirm network participation

Confirm that your mid-level providers are

listed as participating in our network by

calling our Provider Service Center:

•1-800-632-3862 for HMO-based plans

•1-800-624-0756 for all other plans

If your mid-level practitioners are not listed

asparticipatinginournetwork,visitour

website for more guidance.

Ifcredentialingisnotrequired,youcan

load the mid-level practitioner directly by

following directions on the link. The

mid-level practitioners appear as

participating in our DocFind,online

provider directory.

* Clinical nurse specialists may be nurse

practitioners(NPs)orregisterednurses(RNs).

IfanRNisprovidingservicesasaclinicalnurse

specialist,thebillingrequirementswillapply.

Experimental or investigational lab tests are not covered

We sometimes hear from members who

unexpectedly had to pay for laboratory

tests they believed were covered under

their health plan.

Intheseinstances,theirphysiciansordered

thesetests.However,thetestswere

experimentalorinvestigational,based

upon evidence-based standards. As a

result,theywerenotcoveredunderthe

terms of the member’s health plan and we

denied the claim. Your patient then had to

pay out of pocket for these services.

So,ifyouorderanon-coveredtest,weask

you to make sure your Aetna patients are

aware of this.

What tests are affected

We list laboratory tests that are not

covered or that may be conditionally

covered on our secure provider website.

Toseewhatthesetestsare,select“Claims”

fromtheAetnaPlanCentralhomepage,

then “Clinical & Payment Policy Code

Lookup,”thenthe“Selectacodeby

Category” drop-down menu.

If you have questions about these

procedures,refertothecorresponding

Clinical Policy Bulletin to review

the medical evidence we use to base

our position.

Precert for lumbar laminectomy and laminotomy procedures

Last year we notified you that the treating

surgeon is required to obtain

precertification for inpatient and

outpatientcervical,thoracic,orlumbar

laminectomy and laminotomy procedures.

Theseproceduresrequiremedicalreview,

which means you must submit the

necessary supporting clinical information.

We’ll make a decision after we receive and

review all the needed clinical information.

We are also asking you to get us this

information well before the date of service.

We need at least 7 days when the

procedure is scheduled well ahead of time.

This will allow time for us to conduct the

medical necessity review and avoid

changes or delays to the scheduled

procedure date.

Viewthese

Clinical Policy Bulletins online.

Searchfor16,591and743.

JUNE 2013

Office News

Certain Medicare Advantage plans cover annual physicals

The March issue of Aetna OfficeLink Updates

noted that our Medicare Advantage (MA)

plansnowcoveranannualwellnessvisit,

and no longer cover annual routine

physicalexams.However,wewillcoverthe

annual routine physical exam for some plan

sponsors that elected to offer coverage

for these exams under their group MA plan

in 2013.

A partial list of these employers includes:

•Aetna,Inc.

•Barnes

•CabotCorporation

•DowChemical

•FrontierCommunications

•GE

•IBM

•PhoenixCompanies

•SERS(StateEmployeesRetirement

System)

•STRS(StateTeachersRetirementSystem

of Ohio)

Applicable CPT codes

The CPT codes for routine physicals are

99381-99397and99401-99404,or

99201-99205and99211-99215with

primary diagnosis of preventive. The

preventive diagnosis codes are:

•V03.0-V03.9

•V04.0-V04.89

•V05.0-V05.9

•V06.0-V06.9

•V70.5

Check patient eligibility

Find out if an Aetna MA plan member has

coverage for annual routine physical

exams,andcheckeligibilityandcost

sharing information before you see them

through either:

•Oursecure provider website,or

•OurAetnaVoiceAdvantage

(AVA)

telephone system

Reprocessing denied claims

We will automatically reprocess any denied

claims for an annual routine physical exam

if the exam meets both of these criteria:

•PerformedonorafterJanuary1,2013

•Performedforapatientenrolledinan

Aetna group MA plan that includes

coverage for the exam



TheAmericanBoardofInternalMedicine

(ABIM)Foundationandseveralleading

medicalorganizationslastyearunveiled

Choosing Wisely

. This program

encourages doctors and patients to talk

about tests and procedures that may be

duplicativeorunnecessary–andthatcan

sometimes cause harm.

We support this initiative because:

•Thereisnosinglesolutiontoimprove

health care quality and reduce its cost.

•Webelievethateverysegmentofthe

health care system plays a role.

•Wesupportthecreationofsafer,more

effective and more affordable health

care. We do this through clinical evidence

and collaboration with all those involved

in our health care system.

You can support this effort by:

•Talkingwithpatientsaboutwhyyou’re

prescribingcertaintests,proceduresor

courses of treatment

•Reviewingandusingthelatestclinical

evidence

•Understandinghowyour

recommendations can affect your

patients’ physical and financial health

Submitting claims for Supplemental Retiree Medical Plan

TheAetnaSupplementalRetireeMedical

Planisafullyinsured,non-network-based

commercial retiree group health product.

Formembersenrolledinthisplan,claims

for Medicare-covered services should be

submitted to Original Medicare. Aetna will

receive any claim with a balance bill from

Original Medicare. The only claims you

should submit directly to Aetna for this

plan are those relating to non-Medicare-

covered services.

Plan eligibility

This plan is offered only to retirees and

their eligible dependents enrolled in

Original Medicare. It offers supplemental

benefits and coverage that is similar to true

Medicare Supplement (Medigap) plans.

However,inmoststates,thisproductisnot

a Medicare Supplement plan.

AetnaSupplementalRetireeMedicalPlan

members must seek any Medicare-covered

services from licensed health care

professionals who are eligible to receive

paymentunderOriginalMedicare,unless

otherwise noted in plan documents.

It is important to confirm member benefits

as multiple benefits plans are available.

Call 1-800-557-5078 (TTY/TDD:

1-888-200-6124) with questions.

Talk with patients about appropriate tests

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Verify dependent eligibility in advance to reduce claim rejections

To prevent dependent claims from being

rejected,youshouldverifydependent

eligibility before submitting your claims.

Use our eligibility and benefits inquiry

transaction,whichareavailableonour

secure provider website.

If you submit a claim for a dependent that’s

notonthesubscriber’splan,you’llseethe

following codes on your rejected claims

report:

•CategoryCodeA3

-Acknowledgement/Returnedas

un-processable claim. The claim/

encounter was rejected and has

not been entered into the

adjudication system.

•StatusCode109

- Entity not eligible.

- Note: This code requires use of an

Entity Code.

•EntityCode:D0:DataSearch

Unsuccessful

- The payer is unable to return status on

the requested claim(s) based on the

submitted search criteria.

Claims tips

•Parentsofnewbornsgenerallygetupto

31 days to add newborns to their plan.

•Don’tenterinformationfordependents

(whether newborns or other dependents)

in the indicated fields for the subscriber.

Duringeligibilityverification,welookfor

a combination of member name and ID

number to match in our eligibility system

before we can accept the claim.

Maternity inpatient precertification reminder

Precertification is required for newborn

and maternity inpatient confinements if

the total length of stay exceeds:

•3daysforavaginaldelivery

•5daysforaCesareansection

Precertification is not required for

newborn and maternity inpatient

confinements related to routine delivery if:

•Thetotallengthofstayis3daysorless

for a vaginal delivery

•Thetotallengthofstayis5daysorless

for a Cesarean section

What to do

Call Aetna for precertification when the

confinement exceeds the standard length

of stay for maternity/newborn

confinements. Precertification is the

participating provider’s responsibility when

confinement exceeds the standards. If you

don’tprecertify,Aetna,employersand

members are not responsible for any costs

for services that require precertification.

Precertification requirements apply to all

Aetnaplans,otherthanTraditionalChoice.

Note this CMS address change

The Centers for Medicare and Medicaid

Services (CMS) has a new address for

facilities to submit approvals and

recertification letters for percutaneous

transluminal angioplasty (PTA) of the

carotid artery concurrent with stenting.

Besuretousethisnewaddresswhen

submitting approval requests and

recertification letters for PTA.

The address is:

Director,CoverageandAnalysisGroup

7500SecurityBoulevard

Mailstop S3-02-01

Baltimore,MD21244

We’re here to help

Ifyouhaveanyquestions,callusat

1-888-247-1029.

JUNE 2013

Learning Opportunities

Courses

Continuing Education

•NewCulturalCompetence,MentalHealth

and Depression (CME)

•  NewCulturalCompetence,MentalHealth

and Depression for Case Managers (CCM)

•  NewCulturalCompetence,MentalHealth

and Depression for Nurses (CE)

Accountable Care

•NewAccountableCare-ARisingSolution

Credentialing

•UpdatedCredentialingMadeEasier

Reference Tools

•NewProducts,ProgramsandPlans:Care

Considerations

•NewProducts,ProgramsandPlans:

AcceleratedDeathBenefitFactSheet

•  NewProducts,ProgramsandPlans:

AcceleratedDeathBenefitRealCase

•  Updated The Health Care Professional

Toolkit

•UpdatedProducts,ProgramsandPlans:

AetnaSupplementalRetireeMedicalPlan

•Updated Claims/Coding: CPT/HCPCS

ClaimEntry–quicktips

•Updated Claims/Coding: CPT/HCPCS

CodingTools–quicktips

•UpdatedCredentialing/Recredentialing:

CAQH reference guide

Effective communication is important in

thediagnosing,treatingandongoing

management of individuals with mental

health conditions. This is especially true in

the case of depression.

Toaddressthisneed,weareofferingthree

mental health cultural competence and

cross-cultural communication training

coursesformentalhealthphysicians,

nurses and case managers. You can take

thefreecourses–CulturalCompetence,

MentalHealthandDepression*–onour

Education Site.

Medicaldoctors,nursesandcase

managers can earn up to one hour of

continuing education credit. After

completingthisprogram,youshould:

•Betterunderstandhowdepression

impacts the health of diverse populations

•Beabletodescribethekeysocial,

cultural,andexternalfactorsimportantin

caring for diverse populations and racial

and ethnic minorities with depression

•Applywhatyou’velearnedtobetter

understand and manage mental health

conditions across cultures

How to get started

•LoginorregisteratourEducation Site

•TypeMentalHealthinthesearchfield

•Click“Go”

* This CME course meets state licensure

requirementsforphysiciansinCT,MA,NV,PA,NJ

andTX.

New and updated courses for physicians, nurses and office staff

Mental health cultural competency training at no cost

Plain language helps people better understand their health care

You want to reach your patients with health

information they can easily understand

and use. We want that too. Here’s an easy

waytoachievethis–avoidlarge,complex

words (medical jargon) when simpler ones

willdo.Forexample,justsay“heartattack”

instead of myocardial infarction.

Making materials easier to understand

We strive to write simply because we want

our customers to understand the first time

theyreadourmaterials.Toachievethis,we

writecommunicationsata5thgrade

reading level for members and 9th grade

forproviders,plansponsorsandbrokers.

Our internal Writers’ Center for Excellence

(WCFE) website was recently named best

website in the private sector from the

Center for Plain Language at its annual

ClearMark* competition. The WCFE is a

new website that gives our employees tools

to write clearer messages. These materials

help guide our members through a

complex health care system.

Tolearnmoreaboutplainlanguage,visit

the National Institutes of Health website.

* The ClearMark awards celebrate the best in clear

communication and plain language from

government,non-profits,andprivatecompanies.



How to submit Medicare coverage requests using EDI

We want you to submit your Medicare

precertification/notification coverage

requests via Electronic Data Interchange

(EDI) for Aetna Medicare Advantage (MA)

plan members. When using electronic

precertification,youhavethreechoicesfor

servicelevelindicators:elective,urgent

and emergency. Follow these instructions

for using EDI to submit these requests:

•Submitroutinerequests(thatdon’tmeet

the definition for a Medicare expedited

request) with the elective level of service

indicator. You may add “Medicare

StandardRequest”inthecommentsfield.

•Ifyouselecturgent,weclassifythe

request as a “Medicare expedited

request.” These requests must meet the

CMS definition for an expedited or

time-sensitive situation:

A situation where the time frame of the

standard decision-making process could

seriously jeopardize the life or health of the

enrollee, or could jeopardize the enrollee’s

ability to regain maximum function.

•Selecturgent when your Aetna MA plan

patient needs care within 24 to 72 hours

fromthetimeofyourrequest(e.g.,your

patient is admitted directly to the hospital

at the request of the attending or

primary care physician). You may add

“MedicareExpeditedRequest”inthe

comments field.

•Chooseemergency when your Aetna

MA plan patient is admitted to the

facility after receiving services in the

emergency room.

Using the appropriate level of service

indicator will help facilitate this process

and help ensure that we quickly handle

truly emergent and urgent patient

situations.

Electronic Transactions

Get answers to your claims and policy questions

Our secure provider website offers a wide

array of online tools and resources. You can

find the answers you need online.

Here are just a few things you can do on

our site:

•Claims and account management

tools – Submit your claims at no cost.

You can also inquire about individual

claims,runclaimsreportsandaccess

claims policies.

•AccessClaim Explanation of Benefits

anytime.AllofyourEOBActivityistwo

clicks away.

•OurElectronic Precertification

transaction makes submitting your

precert requests easier than ever.

Gohere to learn more.

Check out these resources

Our Resources section links to content such

asClinicalPolicyBulletins,Precertification

ListsandAetnaBenefitsProducts.Wealso

offer many customer support resources in

the Help section.

Take our free webinars

learn about these tools and resources.

Viewtheupcomingwebinarschedulesfor

DoingBusinesswithAetna,AetnaClaim

andAccountManagementTools,

ElectronicPrecertification,andClaim

andEOBTool.

Use secure site to update your demographic data

If you need to update your office’s

demographicinformation–newe-mail

addresses,mailingaddress,phoneorfax

numbers–useoursecure provider

website. Also update your demographic

information if your name changes due to

marriage or another life event.

Our secure site lets you confirm the

information you submit. It prevents

unauthorizedindividualsfromsubmitting

wrong information about your office

or facility.

Electronic transactions

You also can do most electronic

transactions through this website. This

includessubmittingclaims,checking

patientbenefitsandeligibility,and

requestingprecertifications.So,ifyou’ve

been calling our Provider Service Center for

demographic changes or with questions

aboutelectronictransactions,weaskthat

you use the secure site instead.

NaviNet Security Officers have access to

Aetna’s “Update Provider Profiles”

function,throughwhichtheycansubmit

demographic changes. They also can

authorizeotherusers’accesstothis

feature as appropriate. To use the secure

website you must first register.

JUNE 2013

Where to find our Medicare and Commercial formularies

We update the Aetna Medicare and Commercial (non-Medicare)

Preferred Drug Lists at least annually and from time to time

throughout the year. These drug lists are also known as our

formularies,andcanbeaccessedat:

•Medicare Preferred Drug Lists

•Medication Search page for the Commercial Preferred

Drug Lists

Forapapercopyoftheselists,calltheAetnaPharmacy

Management Provider Help Line at

1-800-AETNA RX (1-800-238-6279).

The U.S. Preventive Services Task Force (USPSTF) recommends

screening all adults for obesity. We recommend that you calculate

thebodymassindex(BMI)foralladults.Then,documentthevalue

in the patient’s medical record at least every other year.

ForpatientswithaBMIof30kg/morhigher,considerreferring

them for additional help/intervention.

What you can do

•PrintaBMI table.

•Postitnexttoyourscale.

•Recordthepatient’sBMI.

•UsetheNationalInstitutesofHealth

BMI calculator.Or,downloadtheBMIcalculatoriPhone app.

It’s easy to calculate body mass index

Consult Clinical Practice Guidelines as you care for patients

The National Committee for Quality Assurance (NCQA) requires

health plans to regularly let providers know about the availability

ofClinicalPracticeGuidelines(CPGs).

OurCPGsandPreventiveServiceGuidelines(PSGs)arebasedon

nationallyrecognizedrecommendationsandpeer-reviewed

medical literature. They are on our secure provider website.

Lookunder“AetnaSupportCenter,”then“ClinicalResources.”

Preventive Service Guidelines

*USPSTF intimate partner violence screening recommendation

**CDC tdap vaccine for pregnant women

Adopted 2/12

Adopted 3/13

Behavioral Health

•HelpingPatientsWhoDrinkTooMuch

•TreatingPatientsWithMajorDepressiveDisorder

Adopted 2/12

Diabetes

•TreatingPatientsWithDiabetes Adopted 2/13

Heart Disease

•TreatingPatientsWithCoronaryArteryDisease Adopted 4/12

ForahardcopyofCPBs,oraspecificCPG,callourProviderServiceCenterat1-888-632-3862.

*U.S. Preventive Services Task Force **Centers for Disease Control and Prevention

Precert for Medicare inpatient services

We still require precertification for inpatient services when Medicare is primary insurer. Even when Aetna is the secondary insurer to

Medicare,precertificationforinpatientservicesisrequired.

Facilities should notify us upon admission of inpatient services. Learn more.



Mid-America News

Asareminder,manyofyourAetnapatientsrequireareferralfrom

their PCP to see a chiropractor. If the chiropractor you refer the

member to is participating with American Specialty Health (ASH

Group),submitthesereferralsdirectlytoASHGroupsothatclaims

can process correctly.

If the chiropractor you refer the member to is participating with

ASHGroup,besuretosubmitthereferraltoASHwiththe

state-specificASHGroupPIN:

•ASH–IL–PIN#9928729

•ASH–OH–PIN#9160679

Followingtheinitialreferral,additionalreferralsfromthePCPare

required when:

•Thepatientrequiresadditionalvisitsbeyondtheinitialreferral

request.

•Thechiropractorrefersthepatienttoasecondchiropractor.

•Thechiropracticvisitsrequireanextensionbeyondthe“referral

thru date.”

Ifyouhavequestionsaboutthisprocess,contactASHat

1-800-972-4226,option2.Theirrepresentativesareavailable

MondaythroughFriday,7a.m.-8p.m.CT.

PCPs: Send chiro referrals directly to American Specialty Health

Texas

Aspartofourroutineupdates,we’readjustingdrugcodeand

immunizationreimbursementforallofourplansinyourmarket.

Our injectable reimbursement is based on Centers for Medicare &

Medicaid Services (CMS) with market relativities.

ForcodesnotvaluedbyCMSandforimmunizations,oursource

for Average Wholesale Price (AWP) with market relativities is

R.J.Health.

Scheduled updates for 2013

Wearealsoupdatingourinjectabledrugandimmunizationcodes

quarterlyeffectiveJanuary1,April1,July1andOctober1.Youcan

access these quarterly rates on our secure provider website.

Onceloggedin,select“Claims”then“FeeSchedules.”Or,callour

Provider Service Center.

Updates include immunizations and injectable drugs

JUNE 2013

Aetna Medicare now covers Teacher Retirement System of Texas

AsofJanuary1,2013,Aetnabeganofferingacustomgroup

Medicare Advantage PPO Plan with Extended Service Area (ESA) to

eligibleTeacherRetirementSystemofTexas(TRS)retireesand

dependents.

Plan benefits and payment information

This Plan provides all the benefits covered under Original

Medicareandmore,suchasunlimitedinpatienthospitaldaysand

coverage for preventive services. Members enrolled in this plan

have the flexibility of seeing either participating providers or

nonparticipating providers who meet both of these criteria:

•EligibletoreceivepaymentfromMedicare

•Agreetoaccepttheplan

TheAetnaMedicarePlan(PPO)withESAofferedtoTRSretirees/

dependents has the same precertification requirements as the

AetnaMedicarePlan(PPO).HereareexamplesoftheTRSIDcards

for this plan:

Additional information

For more information about Aetna Medicare Advantage (MA) plans:

•Visitoursecure provider website

•VisitourEducation Site for easy access to training and resources related to our MA plans

Notice of Material Amendment to Contract

Forimportantinformationthatmayaffectyourpayment,compensationoradministrativeprocedures,seethefollowingarticlesin

this newsletter:

•Clinical,codingandpolicychanges-pages2-3

•CertainMedicareAdvantageplanscoverannualphysicals–page5

•Clinicalpracticeguidelinesupdate–page9

Ohio

www.aetna.com

48.22.808.1-Q2-MA (6/13)

The information and/or programs described in this newsletter may not necessarily apply to all services in this region. Contact your Aetna

network representative to ﬁnd out what is available in your local network. Application of copayments and/or coinsurance may vary by plan

design. This newsletter is provided solely for your information and is not intended as legal advice. If you have any questions concerning

the application or interpretation of any law mentioned in this newsletter, please contact your attorney.

UndertermsofyourAetnacontract,you

are required to notify us whenever:

•Aphysicianleavesyourpracticeoranew

physician joins your practice

•Yourofficechangesitsmailingaddress,

phone number and/or fax number

•Thereisachangetothee-mailaddressof

anyone in your office

•Yourofficepanelstatuschanges(e.g.,if

you want to re-open your practice to new

patients(currentlyfrozen)orifyour

practice is accepting current patients

only)

Ifwedon’tgetthisinformationfromyou,

your practice may not receive important

information that we send either by e-mail

orU.S.mail.Plus,thishelpsuskeepdata

about your practice current.

Medicare Advantage

If you are contracted for Medicare

Advantage(MA),thisisalsoaCentersfor

Medicare & Medicaid Services (CMS)

requirement. Your Aetna agreement

requires that you comply with all applicable

Medicarelaws,rulesandregulationsand

CMS requirements. Per Medicare

regulations,CMSrequiresMA

organizationstomakeagoodfaitheffort

to provide MA members with 30 days

advance written notice when a provider is

terminating from the MA network.

How to contact us

You can give us this information through

our secure provider website. On the

AetnaPlanCentralpage,choose“Update

Aetna Provider Profile.” If you have

questionsaftergoingonline,callour

Provider Service Center.

Route this publication to:

OceManager

ReferralandPrecerticationStat

BusinessSta

FrontDeskSta

MedicalRecords/MedicalAssistants

Primary Care Physicians

Specialists

Physician Assistants/Clinical

Nurse Specialists

Nurses

“Aetna” is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies

that offer, underwrite or administer benefit coverage include Aetna Better Health Inc., Aetna Health Inc., Aetna Health of California Inc, Aetna Dental

Inc., Aetna Dental of California Inc., Missouri Care, Incorporated, Aetna Life Insurance Company, Aetna Health Insurance Company of New York, and

Aetna Health Insurance Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

Tell us when a provider leaves your practice or facility