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Office Manual for
Healthcare Professionals
Mid-America regional section
www.aetna.com
23.20.803.1 (3/14)
Welcome to Aetna’s Office
Manual for participating
physicians, facilities and
office staff.
Aetna Performance Network 03
Contacts 05
External review 08
Gynecologist as principal physician for
Women’s Health Care Program (Texas only) 09
Hospitalist programs in Kansas City and St. Louis 10
Radiology accreditation requirements 10
Primary care physician initial lab designation
and change request forms 10
Specialist as primary care physician (Texas only) 11
Specialist as Principal Physician Direct
Access program (Oklahoma and Texas) 11
Utilization management timelines (Texas only) 12
Utilization review policies 12
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 benefits coverage include Aetna Health Inc., Aetna Health of
California Inc., Aetna Health of the Carolinas Inc., Aetna Health of Illinois Inc., Aetna Life Insurance Company, Aetna Health
Insurance Company of New York, Aetna Health Insurance Company, Aetna Health Administrators, LLC, Cofinity, and
Strategic Resource Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management,
LLC (Aetna).
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Aetna Performance Network
Employers and employees look to us for options to help better
control costs. That’s why we created the Aetna Performance
Network (APN).
When a member needs a procedure that requires a hospital visit,
research shows that most members choose the doctor before
they choose the hospital. And they choose the hospital based
on where their doctor has privileges. The APN tightly aligns 20
specialties that drive medical costs to top-performing hospitals.
To create the network:
•We evaluated our participating hospitals based on certain
cost and quality criteria. In some cases, we applied other
business considerations.
•We looked at specialists in 20 categories that frequently use
those hospitals. Specifically on their usage of tier 1 hospitals.
In some markets, we also reviewed 12 out of 20 specialties
on additional measures for clinical quality and cost.
Our members pay a lower percentage of their medical costs
when they use these APN doctors and hospitals.
Specialties evaluated for APN
•Allergy/ immunology
•Cardiology*
•Cardiothoracic surgery*
•Dermatology
•Endocrinology
•Gastroenterology*
•General surgery*
•Infectious disease
•Nephrology
•Neurology*
•Neurosurgery*
•Obstetrics/gynecology*
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•Ophthalmology
•Orthopedics*
•Otolaryngology (ENT)*
•Plastic surgery*
•Pulmonary critical care
•Rheumatology
•Urology*
•Vascular surgery*
Specialties designated based on Aexcel criteria in Aexcel
market locations and further refined by their utilization of APN
hospitals.
Where it’s currently available
•Arizona
•California (Central Valley, Los Angeles, Northern California,
Orange/Inland, San Diego)
•Connecticut
•District of Columbia (Washington, D.C.)
•Florida (Brevard County, Northern Florida, South Florida –
Palm Beach and Broward Counties, Tampa)
•Georgia (Augusta, Savannah)
•Illinois (Chicago)
•Indiana (Indianapolis)
•Kentucky (Louisville)
•Maine
•Massachusetts
•Nevada (Las Vegas)
•New Hampshire
•New Jersey (Northern, Southern)
•New York (Metropolitan New York City, Upstate)
•North Carolina (Charlotte, Raleigh−Coastal−Greenville,
Winston-Salem)
•Ohio (Cincinnati, Cleveland, Toledo)
•Oklahoma (Oklahoma City, Tulsa)
•Pennsylvania (Northeast−Scranton, Southeastern−
Philadelphia)
•South Carolina
•Tennessee (Chattanooga, Nashville)
•Texas (Austin, Houston, San Antonio)
•Virginia (Hampton Roads, Richmond, Roanoke)
•West Virginia
•Wisconsin (Southeastern)
To find a doctor or hospital in the APN, visit DocFind®, our
online provider directory.
Savings Plus
We created Savings Plus to help employers and employees
better control costs. Savings Plus tightly also aligns specialties
that drive medical costs to top-performing hospitals.
To create the network:
•We evaluated our participating hospitals based on certain
cost and quality criteria. In some cases, we applied other
business considerations.
•We looked at providers in up to 22 specialty categories who
frequently use those hospitals. This included primary care in
certain markets.
Our members get the highest level of benefits when they use
these Savings Plus doctors and hospitals.
Specialties evaluated for Savings Plus
•Allergy/immunology
•Cardiology
•Cardio thoracic surgery
•Dermatology
•Endocrinology
•Gastroenterology
•General surgery
•Hematology/oncology
•Infectious disease
•Nephrology
••Neurology
•Neurosurgery
•Ob/gyn
•Ophthalmology
•Orthopedics
•Otolaryngology
•Plastic surgery
•Primary care
•Pulmonary critical care
•Rheumatology
•Urology
•Vascular surgery
Where it’s currently available
•Arizona (Maricopa, Pima, Pinal)
•Chicago (Chicago area, Lake County, Northwest Indiana)
•Florida (Brevard County, Tampa)
•Ohio (Lake County area)
•Oklahoma (Oklahoma City, Tulsa)
•Texas (Austin, Houston, San Antonio)
To find a doctor or hospital in Savings Plus, visit our DocFind,
our online provider directory. Choose the Savings Plus plan in
your search selections.
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Contacts
Allergy extract vendor
Nelco Lab
Phone: 1-800-541-0790
Chiropractic services
For all products, including Medicare Advantage:
American Specialty Health
Phone: 1-800-972-4226
•Chicago, IL
•Ohio
All other markets: Visit DocFind, our online provider directory.
Complaints and appeals address
Aetna Complaints and Appeals
PO Box 14020
Lexington, KY 40512
Denta
Visit DocFind, our online provider directory.
Durable medical equipment (DME)
Visit DocFind, our online provider directory.
Enhanced Clinical Review Program
Preauthorization is required for the following procedures:
•Elective outpatient MRI/MRA, nuclear cardiology, PET scans,
CT/CTA
•Facility-based sleep studies
•Elective outpatient stress echocardiography and diagnostic
left and right heart catheterization
•Elective inpatient and outpatient cardiac rhythm implant
devices
Preauthorization is required for all Aetna members enrolled in
our commercial and Medicare Advantage benefits plans in
the following areas:
•Illinois
•Indiana
•Kansas
•Kentucky
•Michigan
•Missouri
•Ohio
•Oklahoma
•Texas
•Wisconsin
Preauthorization requests should be made by contacting
MedSolutions at:
•Phone: 1-888-693-3211
•Fax: 1-888-693-3210
Home health
CSI Network Services
Phone: 1-888-873-7888
•Michigan
•Ohio
All other markets: Visit DocFind, our online provider directory.
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Home infusion
CSI Network Services
Phone: 1-888-873-7888
•Michigan
•Ohio
All other markets: Visit DocFind, our online provider directory.
Hospice
CSI Network Services
Phone: 1-888-873-7888
•Michigan
•Ohio
All other markets: Visit DocFind, our online provider directory.
Laboratory
Aetna’s network offers your patients access to a nationally
contracted, full-service laboratory. It has conveniently
located Patient Service Centers.
Quest Diagnostics® is our national preferred laboratory. It
provides tests and services to all Aetna members.
Find a convenient location, schedule an appointment and get
testing reminders by visiting Quest Diagnostics or calling
1-888-277-8772.
Your market may also have contracted with local laboratory
providers such as:
Michigan
•Joint Venture Hospital Laboratories www.jvhl.org
Oklahoma
•Diagnostic Laboratory of Oklahoma
•Regional Medical Labs
•Saint Francis Hospital Outreach Service, LLC
Texas
•ProPath Laboratory, Inc. Memorial Hermann Diagnostic
Laboratories (Houston market)
For a complete list of participating labs available in your area,
visit DocFind, our online provider directory.
Non-participating provider and special services request
For HMO-based products:
1-800-624-0756
For PPO-based products:
1-888-MD-Aetna (1-888-632-3862)
Paper claims address
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Aetna
PO Box 981106
El Paso, TX 79998-1106
Physical therapy and occupational therapy (PT/OT)
American Therapy Administrators
Phone: 1-888-560-6855
•Kansas and portions of Missouri (HMO only)
•North Texas (DFW)
•South Texas (Houston, San Antonio and Austin)
•Oklahoma (Oklahoma City, Tulsa)
Rehab Provider Network (RPN)
Phone: 1-888-256-2248
•Ohio only
All other markets: Visit DocFind, our online provider directory.
Radiology
Visit DocFind, our online provider directory.
Respiratory Therapy
Visit DocFind, our online provider directory.
Skilled Nursing Facility networks
For all Mid-America markets:
Management Network Services (MNS)
Phone: 1-800-949-2159
For additional participating providers, visit DocFind, our
online provider directory.
Speech Therapy
American Therapy Administrators
Phone: 1-888-560-6855
•Kansas and portions of Missouri (HMO only)
•North Texas (DFW)
•South Texas (Houston, San Antonio and Austin)
•Oklahoma (Oklahoma City, Tulsa)
Rehab Provider Network (RPN)
Phone: 1-888-256-2248
•Ohio only
All other markets: Visit DocFind, our online provider directory.
Vision networks
Eyemed
Phone: 1-888-581-3648
For participating providers, visit DocFind, our online provider
directory.
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External review
External review offers members the chance to have certain
coverage denials reviewed by independent physician reviewers.
Once the applicable plan appeal process has passed, eligible
members may request external review if:
•The coverage denial for which the member would be
financially responsible involves more than $500.
•It’s based on lack of medical necessity, or on the experimental
or investigational nature of the service or supply at issue.
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Keep in mind that certain states mandate external review
of other benefits or service issues or require a filing fee. Also,
certain states mandate the use of their own external reviewer.
These state mandates may not apply to self-funded plans. For
example, the state of Texas mandates an Independent Review
Organization for fully-insured plans.
•Request for External Review Form
•Request for Expedited External Review Form
Gynecologist as principal physician for Women’s Health
Care Program (Texas only)
The direct-access program allows female members to visit
any participating gynecologist for women’s health-related
care without a referral.
We’re expanding the program to allow the gynecologist to
issue referrals for women’s health and non-women’s health
conditions detected during a visit. In this instance, the
gynecologist can refer the member to the appropriate
specialist and continue overseeing the member for that
condition. Or, the gynecologist can request that the member’s
primary care physician (PCP) follow up and provide oversight.
In addition, in keeping with Aetna’s expanded laboratory and
radiology policy, the gynecologist can order any necessary
laboratory or radiological testing without a referral. (This
excludes pregnant women who are participating in our
Beginning Right® Maternity Program.) The member should
be referred to the appropriate capitated or contracted labs,
if applicable.
How to bill
The gynecologist or PCP who performs the annual
gynecologic primary and preventive visit should bill using the
E&M codes for preventive visits (99384-7 and 99394-7).
All other visits to the gynecologist should be coded using
standard E&M codes. The gynecologist will collect the
standard specialist copayment. When a woman uses both a
gynecologist and a PCP for her care, the physicians should
work together to coordinate her care. They should use their
standard processes to communicate the treatment plans,
services rendered and summaries of visits.
Parts of the Aetna gynecologist as principal physician for
Women’s Health Care Program allows:
•The gynecologist to act as the principal physician for all of
women’s health care. It empowers the woman to choose
either her gynecologist or her PCP to care for her needs at
that particular time in her life based on the expertise of the
physician she chooses.
•The woman to be evaluated by her gynecologist without a
referral from the PCP.
•The gynecologist to perform and be paid for diagnostic
testing that can be done in his/her office. This includes
studies on the “Automatic List” as well as screening and
diagnostic mammography, pelvic ultrasounds, urodynamic
testing and bone density testing.
•The gynecologist to refer the member for all laboratory and
radiological studies needed without requiring a referral
from her PCP. All laboratory or radiological testing should
continue to be performed at the capitated facility linked to
the woman’s PCP, or if there is no capitated network, at any
participating laboratory or radiology facility in the relevant
network.
•The gynecologist to refer members to any participating
specialist or PCP in our network (except in Independent
Practice Association [IPA] networks) for evaluation and
treatment of any condition detected during a gynecological
visit. Follow-up care by a specialist physician can be
coordinated through either the PCP or the gynecologist.
•The gynecologist to precertify an admission when the
patient needs to be admitted to a short procedure unit or
hospital for surgery and the gynecologist is the admitting
physician. This precertification process will automatically
generate the referral for the procedure to ensure payment
without the need for the member to get a referral from a
PCP. Precertification for the site of therapeutic abortions
may be dependent on regional facilities and the
participation of doctors who perform these procedures in
their office or in cost-effective facilities.
Note: Depending on a member’s plan, referrals to out-of-network
providers may not be covered or may result in substantial
out-of-pocket costs to the member.
Certain providers may be affiliated with an IPA, Physician
Medical Group (PMG), Integrated Delivery System (IDS), or
other provider group. Members who select these providers
will generally be referred to specialists and hospitals affiliated
within or otherwise affiliated with those groups.
Women’s Health: Variations from the national program
for the state of Texas
For information on our Aetna Women’s HealthSM Programs,
refer to the Women’s Health Programs & Policies manual.
Or, visit our secure provider website. Once logged in, go to
Clinical Resources > Main Page > Women’s Health Programs
& Policies.
Note (Texas only): Obstetrical ultrasounds performed in the office
do not require an authorization and are paid on a fee-for-service
basis. Austin, Corpus Christi and San Antonio markets do not
participate in the non-stress test (NST) enhancement program and
are paid on a fee-for-service basis.
NOTICE: The term “precertification,” used here and
throughout the Office Manual, means the utilization review
process to determine whether the requested service,
procedure, prescription drug or medical device meets our
clinical criteria for coverage. It does not mean precertification
as defined by Texas law, as a reliable representation of
payment of care or services to fully insured HMO and PPO
members.
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Hospitalist programs in Kansas City and St. Louis
Hospitalists can act as referring physicians for the
coordination of adult medical and surgical inpatient services.
They may admit members, evaluate members in the
emergency room, and coordinate all clinical services that
members require.
documentation of your patient’s status on admission, during
the stay, and upon discharge. They will also contact members
upon discharge to assess their post-discharge progress. And,
they will assess if the member is receiving appropriate
follow-up care.
They also work closely with our Case Management
Department to help with continuity of care on discharge or
transfer to an alternate level of care.
The use of any participating hospitalist physician’s services is
strictly voluntary, and in any circumstance where a member
objects to the hospitalist attending to his/her care, the PCP
will be informed so that he or she can reassume direction of
the patient’s care.
As part of their obligation to you and our members,
hospitalists will provide notification and written
Radiology accreditation requirements
Aetna has radiology accreditation requirements for our
commercial and Medicare Advantage business.
To be eligible for reimbursement for the technical part of
advanced diagnostic imaging procedures, the following types
of providers must be accredited by the American College of
Radiology (ACR) and/or the Intersocietal Accreditation
Commission (IAC):
•Freestanding imaging centers
•Independent diagnostic testing facilities
•Non-physician practitioners
•Office-based imaging facilities
•Physicians
•Suppliers of advanced diagnostic imaging procedures
This accreditation requirement applies to the technical
part of advanced diagnostic imaging procedures. For these
purposes, advanced diagnostic imaging procedures exclude
X-ray, ultrasound, fluoroscopy and mammography.
Included are:
•Computed tomography (CT)
•Echocardiograms
•Nuclear medicine imaging, such as positron emission
tomography (PET)
•Single photon emission computed tomography (SPECT)
Note:
•Providers not accredited by the ACR or IAC by January 1, 2012,
will not be eligible for payment for advanced diagnostic
imaging services.
•This requirement will not apply to patients who are in the
hospital or in hospital emergency departments.
•This policy will not apply to hospitals, unless they own one
of the above listed providers.
•The accreditation process can take 9 to 12 months.
•Magnetic resonance imaging (MRI)
•Magnetic resonance angiography (MRA)
Primary care physician initial lab designation and
change request forms
Refer to the forms library for the Initial Lab Designation and
Change Request Forms for Oklahoma and Texas. Log in to our
secure provider website. Once there, go to > Plan Central >
Aetna Health Plan > Aetna Support Center > Forms Library >
Lab Selection Forms.
10
Specialist as primary care physician (Texas only)
A full-risk HMO member may apply to the health plan to use a
non-primary care specialist as a primary care physician (PCP).
The written request must include:
•Certification by the non-PCP specialist of the medical need
for the member to use the non-PCP specialist as a PCP.
•A statement signed by the non-PCP specialist that he/she is
willing to accept responsibility for the coordination of all of
the member’s health care needs.
•The signature of the member.
The non-PCP specialist must meet the health plan’s
requirements for PCP participation, including credentialing.
The contractual obligations of the non-PCP specialist must
be consistent with the contractual obligations of the health
plan’s PCPs.
For help, call Patient Management at the number on the
member’s ID card.
Specialist as Principal Physician Direct Access program
(Oklahoma and Texas)
The voluntary Specialist as Principal Physician Direct Access
(SPPDA) Program provides eligible members suffering from
serious or complex medical conditions with direct access to
covered specialty care.
Program details
HMO-based members with serious or complex medical
conditions who require ongoing specialty care are eligible for
participation in the program. “Serious or complex medical
conditions” are medical conditions or diseases that are:
•Life-threatening
•Degenerative
•Disabling
Examples include: AIDS, cancer, chronic and persistent
asthma, diabetes with target organ involvement,
emphysema, and organ failure that may require transplant.
To help promote continuity of care for members participating
in the SPPDA program, these members’ primary care
physicians (PCP) will continue to play an active role in
coordinating their care. PCPs will:
The SPPDA program is in addition to existing programs by
which eligible members may directly access covered
obstetric/gynecologic, mental health, substance abuse, or
routine vision services or treatment. The program is not
available to members suffering from conditions that are not
serious or complex. Members with such conditions may,
however, request limited standing referrals from their PCP.
The member must meet specific medical criteria for
chronicity and severity of a chronic condition as defined
below:
•The PCP must have seen the patient within three months
prior to requesting the direct access authorization.
•The primary diagnosis is based on a chronic disease.
•There may or may not be a secondary diagnosis
(co-morbidity).
•The patient has evidence of severe disease or progression in
spite of treatment.
For help, call Patient Management at the number on the
member’s ID card.
•Help, where appropriate, in drafting any necessary
treatment plans.
•Treat problems unrelated to those that caused the member
to enroll in the program.
•Receive periodic updates concerning the care their patients
have received through the program.
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Utilization management timelines (Texas only)
Type of decision
Aetna will issue response within
Approval notice
2 working days
Adverse determinations notice
1 working day (written notice within 3 working days)
Post-stabilization care, emergency treatment, or
life-threatening conditions
Within the time appropriate to the circumstances, but not
exceeding 1 hour
Appeal of adverse determination
As soon as practical, but no later than 30 days after the date
the appeal is received
Expedited appeal (e.g., life-threatening conditions, continued
stays for hospitalized patients)
1 working day or in accordance with the medical immediacy
of the case
Health care providers may request a review by a provider in
the same or similar
specialty—one who typically manages the condition. They
can do this by submitting a written request for review of the
appeal within 10 working days of receiving the adverse
determination.
For more information on precertification and utilization
management review, see the Patient Management and Acute
Care section.
Utilization review policies
Aetna has a utilization review/patient management program
for determining what health care services are covered and
payable under the health plan and the extent of such
coverage and payments. The program helps members:
•Receive appropriate health care
•Maximize coverage for those health care services
www.aetna.com
©2014 Aetna Inc.
23.20.803.1 (3/14)
You can find more information on our utilization review
policies, including precertification, concurrent review and
discharge planning, and retrospective review on our public
website.