1. Presented by Your Aetna Team
Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
MEDIA
Presented by Your Aetna Team
November 10, 2016

2. Here today to share information
Your Aetna Contacts:
Robert Willis – Sr. Network Manager
Christine Black – Network Manager (Tompkins)
David Martin – Contract Negotiator (Tioga, Broome, Cortland)
Jane Parry – Network Account Manager (Steuben, Chemung, Schuyler)
Aetna Provider Service Center:
Aetna Credentialing Department:

3. Topics for Today Coding Medical Record Requests Transparency Tools for
Top Claim Submission Errors
Medical Record Requests
Transparency Tools for
Providers and Members
Disputes & Appeals
Practitioner and Provider
Complaint and Appeal Form
Precertification
New Century Health
Medicare Attestation

4. Top Claim Submission Errors
Diagnosis of a medical condition when preventive visit
Incorrect CPT codes
Missing or incorrect modifier
Incorrect member
Failure to get pre-cert or referral
Billing, service location or practice name not matching what is in Aetna’s system. Please notify us with changes.

5. Medical Record Requests
Two primary types of requests from Aetna:
Commercial Risk
Medicare Advantage Chart Audits
Aetna will contract with external vendors to obtain medical
records.
These vendors receive a target list of members and corresponding provider information.
Vendors will contact providers to receive information for targeted members via: Phone call, Letters, s, Fax

6. Medical Record Retrieval Options
• Providers may submit medical records via: — Mail — via secure FTP — Fax • For large volume requests, Providers may work with the medical record retrieval vendor to schedule a time for one of their staff members to come on site to copy the requested medical records. • The medical record retrieval vendor will provide needed contact information to assist providers with handling these requests.

7. Transparency Tools for Providers and Members
Eligibility and Benefit Verification Inquiry
Advises you of eligible coverage, copays, deductibles, coinsurance amounts for various services, availability of benefits with maximums such as preventive care, as well as what has been met toward the out of pocket amounts
Payment Estimator
“real time” estimate of what the patient is responsible for at the time of service
Member’s Website – Navigator
Members may view their benefits and patient responsibility
portions
Estimate the Cost of Care

8. Disputes & Appeals Our process for disputes and appeals
Health care providers can use the Aetna dispute and appeal process if they do not agree with a claim or utilization review decision.
The process includes:
•Reconsiderations: Formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing.
•Level 1 appeals: Requests to change a reconsideration decision, an initial utilization review decision, or an initial claim decision based on medical necessity or experimental/investigational coverage criteria.
•Level 2 appeals: Requests to change a Level 1 appeal decision.
To help us resolve the dispute, we'll need:
•The reasons why you disagree with our decision
•A copy of the denial letter or Explanation of Benefits letter
•The original claim
•Documents that support your position (for example, medical records and office notes)

9. Disputes & Appeals Have dispute process questions?
Contact our Provider Service Center (staffed 8 a.m. – 5 p.m. local time):
• for HMO-based benefits plans and WA Primary ChoiceSM plans
• for indemnity and PPO- based benefits plans
Mailing addresses for reconsiderations
Aetna Provider Resolution Team
PO Box
El Paso, TX
Mailing addresses for complaints and appeals
PO Box 14020
Lexington, KY 40512
In today’s environment of rising health care costs, members are being asked to take more responsibility for their health care decisions and expenses. To do so, they need access to cost and quality of care information to help them become more educated health care consumers. Aetna offers Estimate the Cost of Care (ECC), a suite of web-based decision support tools, to provide members with estimated average in- and out-of-network costs for selected services, as well as service-specific, health-related content. Members can use the tool to estimate their health care expenses for specific services, as well as see the potential cost savings if they choose an Aetna-participating, in-network provider.
ECC includes the following tools and types of services. For the first 4 tools, members can view estimated in- and out-of-network costs. As noted below, 2 tools contain slightly different information.
Dental Procedures – includes costs for common dental services such as cleanings, fillings, crowns, and child orthodontia.
Diagnostic Tests & Vaccines – includes costs for lab tests, X-rays, MRIs and other tests and vaccines.
Office Visits – includes costs for visits such as routine physicals, specialist visits and emergency room visits.
Surgical & Scope Procedures – includes costs for selected surgeries and procedures such as colonoscopy, sinus surgery and gallbladder removal. _____________________________________________________________________________
Note: the following 2 tools contain slightly different information.
Diseases & Conditions – provides up to a year’s estimated average in-network costs for facility, doctor, pharmacy and medical tests associated with specific diseases and conditions, such as asthma and diabetes, depending on their level of severity.
Prescription Drugs (Price-A-Drug) – members can compare the costs of generic versus brand name drugs for prescriptions filled at participating retail pharmacies, Aetna Rx Home Delivery, or the Aetna Specialty Pharmacy program. Members can also link to information about specific drugs including drug uses and interactions.

10. Timeframes for reconsiderations and appeals
Dispute level
Doctor/Provider submission timeframe
Aetna response timeframe
Contacts
Reconsideration
Within 180 calendar days of the initial claim decision
Within 3-5 business days of receiving the request.
Within 30 business days of receiving the request if review by a specialty unit is needed.
Call: See phone numbers above.
Write: See  mailing addresses below.
Submit online through your secure provider website.
Level 1 and Level 2* appeals
Within 60 calendar days of the previous decision.**
Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information.
Write: Aetna Provider Resolution Team PO Box Lexington, KY
Members can access our tools under the Cost of Care section on the newly designed Navigator home page.
*Level 2 appeals are generally available only to practitioners.

11. Practitioner and Provider Complaint and Appeal Form (Optional)
The Cost of Care page also has a new layout to assist members in searching for information they are looking for.

12. Providers can now access precertification forms from NaviNet via a link to the Forms page on Aetna.com.

13. From the Workflow section, users can select “Precertification, “ then “Precert Information Request Forms.”

14. New Century Health: Oncology Pre-Authorization Effective 04/01/2016
New oncology pre-approval program administered by oncology management company, New Century Health (NCH)
All oncology related chemotherapy drugs and supportive agents will require pre-authorization from NCH (except when the patient is inpatient)
Applies to Aetna Medicare Members and Aetna Commercial Members 18 years or older
Uses clinical guidelines based on nationally recognized, evidence based criteria

15. New Century Health: Oncology Pre-Authorization Effective 04/01/2016
Auth requests can be entered 24/7/365 into the NCH Portal
Eligibility is verified
Real-time approval is granted when selecting treatment care pathways
Reduced documentation requirements
Pre-auth requests should be submitted using NCH’s web portal at
NCH Utilization Management Intake: #5
NCH Staff will provide training as needed

16. Medicare Attestation - NaviNet
Beginning January 1, 2016 first tier, downstream and related entities (FDRs) and their employees must complete the Centers for Medicare & Medicaid Services (CMS) training to meet general compliance requirements. FDRs can access training on the CMS Medicare Learning Network (MLN) website. FDRs now have the ability to complete their Medicare attestation requirements directly from our secure provider website on NaviNet. On NaviNet there are no limitations on attesting for more than 20 tax identification numbers. Users should go to Aetna Plan Central. From the Workflows for this Plan navigation, they should click on Compliance Reporting then Medicare Attestation. A “Medicare Attestation Support Guide” and “User Tip Guide” is available in the Aetna support section in NaviNet. An authorized representative must complete the attestation. FDRs can continue to complete their attestation requirements on Questions: Go to and search “FDR” for more information.

17. Medicare Attestation - NaviNet

18. Credentialing Reminder Apply online at www. aetna
Credentialing Reminder Apply online at under Healthcare Professionals Make sure CAQH is up to date To register your midlevel's: Contact David Martin at or by phone or Jane Parry at or by phone to obtain the midlevel registration form. To check on your application once you have applied please call:

19. Thank you – Enjoy the rest your day!

20. Disclaimer:
The information in this packet is general information only and does not guarantee specific claim payment. You should contact Provider Services at to discuss any specific claim situations.
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