1. Caring for our customers
Fall 2017 Updates

2. Websites Websites for health care professionals www.aetna.com
Information on how to work with us, products & programs, resources for health care professionals and helpful links.
Information on member eligibility, claim status, EOBs, claim reconsiderations, secure s to provider services, claim payment policies, claims reimbursement tool, claims payment estimator and much more!

3. Aetna OfficeLink Updates – News you can use
Aetna OfficeLink Updates delivers timely information for your practice or facility.
The online newsletter is published in March, June, September and December.
Inside each issue providers will find:
Updates to our precertification list
Clinical payment, coding and policy updates
Medicare information
Pharmacy information
Plan and product information
State specific news
Providers may also chose to sign up to receive the electronic communication via located in the OfficeLink section of Aetna’s website.
Newsletters can be found by going to Health Care Professionals, Newsletters & News, Read OfficeLink newsletters and then Mid-America OfficeLink Update newsletter.
All previous copies are stored online as a reference.

4. Aetna at a Glance
A quick reference guide for health care professionals
The quick reference is a great tool to find:
Secure website (NaviNet) resources & information
Secure website (NaviNet) tools and transactions
Claims submission information & claims addresses
Provider Service Center contact information
Contact information specific to the Mid-America Region
This guide can be found by going to Health Care Professionals, Education & Manuals, Explore provider manuals, Read our quick-reference guide.

5. Provider Manuals Provider manuals about our policies and programs
You can view and download these manuals:
Office Manual for Health Care Professionals
Behavioral Health Provider Manual
Women’s Health Programs and Policies Manual
Aetna Benefits Product Guide
Provider manuals can be found by going to Health Care Professionals, Education & Manuals, Explore provider manuals
Coventry Health Care provider office manuals are located on Services & Support, Providers, Document Library, Provider Manual

6. Educational webinars Learn how to work with us electronically
We offer interactive, 45-minute webinars that walk you through how to use our online tools.
How to register for webinars
Register online at Health Care Professionals, Provider Education & Manuals, Educational Webinars and click the Complete the online webinar registration form link.
Sent an to with the name and date of the webinar in the subject line.

7. Claims, Payment & Reimbursement
Convenient tools and guidelines to help you get paid faster
ERA, EFT and Electronic EOB information
Coordination of benefits & claims submission information
Electronic transaction tools
Payment estimator & fee schedule information
Aetna Signature Administrators (ASA) information
Overpayment information
This information can be found by going to Health Care Professionals, Claims, Payment & Reimbursement

8. Disputes & Appeals Process
Our process for disputes and appeals
Log onto Health Care Professionals, Disputes & Appeals to learn more about Aetna’s Dispute & Appeals process
Reconsiderations and Disputes can be submitted online through NaviNet.
The denial determines whether the review requested is a dispute/reconsideration or an appeal.
All appeals require the Practitioner and Provider Complaint and Appeal form or the Member Complaint and Appeal form.
Please see the FAQs for additional information on what is considered an appeal vs reconsideration.
Mailing address for reconsiderations:
Aetna Provider Resolution Team PO Box El Paso, TX

9. Precertification
Precertification occurs before inpatient admissions and select ambulatory procedures and services.
Check the precertification lists by going to Health Care Professionals, Precertification, Check our precertification lists
New updates were made 9/1/17
Search by an individual CPT code
You can submit a precertification request through our secure provider website (NaviNet) or by phone using the number on the member’s ID card

10. Clinical Policy Bulletins
Clinical Policy Bulletins (CPBs) are used to determine medical coverage
CPBs detail the services and procedures we consider medically necessary, cosmetic, or experimental and unproven.
Search our CPBs using
CPT Codes
Key words
CPB number
These bulletins can be found by going to
Health Care Professionals, Clinical Policy Bulletins. Then you can select Medical Clinical Policy Bulletin
claims, code editing, clinical & payment policy look up. There is a look up tool that will show you which CPB is linked to a denial on your claim.

11. Management and Network Services LLC (MNS)
Effective January 1, 2018, MNS won’t be a contracted provider.
MNS will no longer coordinate the skilled nursing services for credentialing or manage authorizations or claims payment.
This change impacts all patients enrolled in Aetna and/or Coventry Medicare, Commercial or network access business (First Health, auto or workers’ compensation) lines of business.
For dates of service on or after 1/1/18, please submit all patient claims directly to Aetna and/or Coventry. Check the back of the member’s ID card for the correct address or claim-payer ID number.
Aetna is currently in the process of contracting directly with all of the skilled nursing facilities.
Effective 1/1/18 Providers will work directly with Aetna for precertification.

12. Keep your information up to date
To update your office’s demographic information, go to NaviNet and sign in.
You should notify us whenever you have:
New or mailing addresses
New phone or fax numbers
Name changes due to marrige or another life event
A new policy regarding accepting new patients
A new hospital or group affiliation
Make sure your CAQH is up to date and accurate
Aetna uses CAQH data to match up and compare to demographic information in our provider systems
Mismatches fall out onto a report for research
If you use CAQH for your credentialing, please make sure that only addresses you are practicing at are listed

13. Aetna plans offered What plans will be available in 2018?
Aetna Plans will include
Commercial HMO, PPO, POS, Open Access plans
Performance network commercial plans offered with the CHI Health ACO, Nebraska Health Network high performance network and MIPPA high performance network
Aetna’s CHI Health ACO product is currently sold in Douglas, Sarpy and Pottawattamie counties additional counties will include: Buffalo, Dawson, Hall, Howard, Lancaster, Phelps and Saline
Medicare plans (Aetna Medicare in Nebraska is only offered as a retiree program for employers at this time)
Aetna Signature Administrators (ASA) contracts directly with TPA’s to access Aetna’s PPO network
For additional information on ASA, please visit
Meritain Health is an Aetna Company that offers the use of Aetna’s national networks

14. Coventry plans offered
What plans will be available in 2018?
Coventry Plans will include
Commercial HMO, PPO, POS, Open Access plans
Performance network commercial plans offered with the CHI Health, Nebraska Health Network and MIPPA high performance networks ** No new employer groups will be offered these plans for These plans will only be offered to employers currently on them in 2017 through the KWYH legislation.
Medicare plans – Coventry Medicare Advantage Plans will remain Coventry until at least 2020
Medicare Advantage HMO & PPO
Coventry Total Care – High performance Medicare network that only includes CHI providers. This product is only sold in Douglas, Sarpy and Pottawattamie counties.
First Health is the rental network for TPA clients to access as payers. For a current listing of First Health clients, please log into
** Due to the KWYH (keep what you have) legislation, Coventry is required to offer employer groups currently on a Coventry plan that same plan for Unless other legislation requires Coventry to change something, all Coventry groups except for Medicare will be offered an Aetna plan for 1/1/19.

15. Aetna Leap Aetna Leap is Aetna’s individual member plans
Aetna Leap plans will not be offered on or off the exchange for 2018
Aetna Leap began 1/1/17 and members will be honored who have paid premiums through 12/31/17
Aetna Leap members only have digital ID cards unless the member has requested a plastic copy be mailed to them
Aetna Leap member eligibility and claims processing are housed on a different claims platform than traditional Aetna
Aetna Leap eligibility checks, claims status, reconsiderations and other electronic tools are available through NaviNet

16. Aetna Leap Issues & Corrections
Aetna Leap Identified Issues
Not all Provider contract information transferred over to the Aetna Leap systems
Providers were not showing all of the correct networks as participating
Providers may still be told they are out of network by Customer Service, we continue to do education when necessary.
If you are told you are out of network and you believe this is not correct, please ask to speak to a supervisor. Please make sure to provide a reference number, name of representative and member information. This assists us with all education and tracking.
Aetna Leap Corrections
We continue to update systems when errors are found or identified
We continue to monitor open projects waiting for reprocessing by meeting weekly with the Leap projects team on status updates
Projects are very back logged but we continue to ask for weekly updates to track progress

17. Questions?