Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 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). 2 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* 3 •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. 4 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. 5 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 6 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. 7 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. 8 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. 9 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. 11 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.
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