1. MI Health Link Providers Lakeland Health System Payer Conference
AETNA BETTER HEALTH® OF MICHIGAN
MI Health Link Providers Lakeland Health System Payer Conference
October 18, 2017

2. Welcome and Introductions
Aetna Better Health of Michigan
Shelia McIntyre, Supervisor Provider Relations
Brian Grcevich, Provider Relations Liaison 2

3. Our Core Values 3

4. Our Members – The Center of What We Do
Operations & Enrollment
Member Services & Member Advocates
Quality Management
Provider Relations & Provider Network
Appeals & Grievances
Medical Management
Collaborative Services 4

5. Member ID cards
New ID cards will be mailed to all new members and whenever a PCP change is made
If the member does not have his/her new ID card, providers can obtain enrollment verification via Secure Web Portal at
A temporary ID card can be faxed to a provider’s office by request;
Just call (TTY 711)
Select Member Services prompt
Members can request a new copy of their card anytime from Member Services 5

6. Member ID Card (Front View)

7. Member ID Card (Back View)

8. Participating Provider Confirmation
Providers Newly Added to the Aetna Better Health of MI Network can be found in our online directory at:
Newly added providers receive a Welcome Letter and Provider Liaison assignment upon acceptance into the Aetna Better Health of Michigan network
Providers can verify their participation status by calling
1(855)
Select Provider Services (Select Option 2, then, Option 6) 8

9. Member eligibility
You can verify member eligibility, PCP assignment, benefits, co-pays/deductibles through three ways:
Continue to use the State CHAMPS system accessed at providers(SOURCE OF TRUTH)
Provider portal
Contract your Provider Relations Team if you have difficulties with 1 & 2 above
1(855) Select Provider Services, (Press Option 2, then Option 1) 9

10. Paper Claims submission
All claims for Aetna Better Health of Michigan should be submitted on the most current claim forms, utilizing correct formats – ICD10 Effective 10/1/2015
Paper claims submission information for Aetna Better Health of Michigan go to:
Paper Claims mailing address
Aetna Better Health of Michigan
P.O. Box 66215
Phoenix, AZ
How to fill out a CMS 1500 Form:
Sample CMS 1500 Form:
How to fill out a CMS UB-04/1450 Form:

11. Electronic/EDI Claims submission
Claims submission information for Aetna Better Health:
Aetna Better Health encourages participating providers to electronically submit claims through Emdeon (Change Health) at
Please use EDI submitter ID #128MI when submitting electronic claims.
Emdeon(Change Health) Office WebConnect is offered at no charge.

12. Claim status BY PHONE: BY Provider Portal:
You can contact Claims Inquiry/Claims
Research (CICR at 1(855)
(Optin2, Option 4)
Our CICR team will:
Assist with Claims questions, inquiries and reconsiderations
Review claims or remittance advices
Assist with claim related prior authorization questions
View recent updates Locate forms
Find a participating provider or specialist
Assist with changes to a practice
(locations, provider termination, etc.)
BY Provider Portal:
Providers can access the provider portal through a link on the public website at

13. Claim resubmissions and reconsiderations
Resubmitted claims must be submitted as a New Claim and can be submitted electronically
Label all corrected claims as “Corrected Claim” on the claim form
Submit all claim lines, not just the line being corrected
Send paper claims for reconsideration with attached documentation to:
Aetna Better Health of Michigan
P.O. Box 66215
Phoenix, AZ
Please download and use the Participating Provider Dispute Form on our website 13

14. Remittance advice
Remittance advices are located within the Aetna Better Health of Michigan new provider portal
Electronic Remittance Advice (ERA) are available via your electronic vendor/clearinghouse, if applicable
Claims and remit information will remain available on our provider portal for up to three (3) years 14

15. Remittance advice 15

16. Electronic tools TWO (2) Enrollment Options for EFT/ERA
Online through our Secure Web Portal
Call Provider Relations at 1(855) ( Option 2, then Option 6)
Electronic remittance advice (ERA-835 files)/Electronic funds transfer (EFT)
Electronic Remittance advice(s) are only available online for providers who signed up for EFT and ERA; all other providers will receive a paper RA
Providers who do not sign up for EFT will receive paper checks
You should work with your clearinghouse to ensure you can receive ERA and have the correct file paths. 16

17. Prior Authorization options
List of Prior Authorization Services (Partial):
Inpatient Services
Long term support services
Surgical services
Therapy
Imaging
Durable Medical Equipment
Dental (select services)
Injectable
Orthotics/Prosthetics
Transportation
For a Complete list of Prior Authorization Services, go to the Provider Portal at then select “ProPat Auth Lookup Tool” 17

18. Medical Prior Authorization
Secure Web Portal
(Only for Network Providers)
Fax
Phone
High Tech Radiology Authorizations
Pharmacy Authorizations
MedSolutions/eviCore:
- By Phone:
1(888)
CaremarkCVS:
- By phone:
1(855) (Option2, Option 2)
1(888) (CVS Caremark)
- By fax: 1(844) (CVS Caremark)
Talking points:
Primary care providers (PCP) or treating practitioner/providers must request authorization for certain medically necessary services. A current list of services which require prior authorization can be found online at Providers may also utilize our Prior Authorization Look up Tool, which is located on our MI Care Bridge (Secure Provider Web Portal).
You may submit prior authorization requests to us 24-hours-a-day, 7-days-a-week through one of three options:
Care Bridge - Secure Web Portal
Fax
Phone
Please submit the following with each authorization request:
Enrollee Information (i.e. spelling of name, ID Number, date of birth, etc.)
Diagnosis Code
Treatment or Procedure Code(s
Anticipated start and end dates of service(s), if known
All supporting relevant clinical documentation to support the medical necessity
Include an office/department contact name, telephone number and fax number
NOTE: A current list of services which require prior authorization can be found online at

19. Member Services Member Services can help with:
Eligibility and benefits
Assisting members with available programs and resources
Assisting members in finding providers
Assisting members in filing grievances or appeals
Call Member Services at 1(855) (Option 1)

20. Provider Relations
Our provider Relations staff is available to you Monday through Friday 8AM-5PM to assist you on any facets of your relationship with Aetna Better Health of Michigan. You can reach Provider Relations BY:
PHONE: Provider Relations Phone – 1(855) (Option 2 then Option 6)
FAX: Provider Relations – 1(844)
Your Aetna Provider Relations Liaison
Brian Grcevich
PH#: (269)
Address: MO

21. Provider Manual
The Aetna Better Health of Michigan Provider Manual will be available. You can find it online at
In addition to policies and procedures, this resource includes:
Important contact information
Provider rights and responsibilities
Credentialing
Member eligibility and enrollment
Billing and claims
Reconsiderations, appeals and complaints
Utilization Management Program and requirements
Quality Improvement Program 21

22. Provider portal
The Secure provider web portal will allow Aetna Better Health of Michigan providers to:
Search member eligibility and verify enrollment
Search and initiate authorizations (CareWebQI)
Search claims status
View claim detail, explanation of benefits and remittance advice
View provider lists and panel roster
Contact the health plan via secure messaging
Review HEDIS gaps in care
Provider portal access
Providers can access the new provider portal at 22

23. Provider portal registration
Providers should register for the provider web portal. To get started:
Complete the web portal registration form
Submit web portal registration form to Provider Relations
Review our provider web portal navigation guide
If you’d like help registering or would like a demonstration, contact Provider Relations at 1 –(855) (Option 2, then Option 6)
Each TIN will have one account, with a primary administrator.
The primary representative can add authorized representatives within their office to their account
Don’t forget to register for the provider web portal. If you have questions, call Provider Relations at 1 (855) . 23

24. Public website
Members and providers can access the Aetna Better Health of Michigan website at
Through the website, providers will be able to access:
The secure provider web portal
Our provider manual, communications and newsletters
A searchable provider directory
A Reconsideration form
Clinical practice guidelines
Member materials
Fraud & abuse information and reporting
Information on reconsideration and provider appeals 24

25. Provider Services Department
CLAIMS
Option 2,
then Option 4
PRIOR AUTHORIZATION
then Option 5
PROVIDER SERVICES
then Option 6

26. Grievance and Appeals Provider Grievances (Complaints)
Must be received within one (1) year of the date of the incident and should include the remit date or date of notice of action that caused the complaint
The complaint should be clearly marked as a “Complaint” on the letter
Provider Appeals
Provider appeals must be received via Fax or Mail within ninety (90) days of the action taken by Aetna Better Health of Michigan, giving rise to the appeal
The appeal letter should clearly note you are filing an “Appeal” on the letter
All documents to support the appeal should be provided, such as a copy of the claim, remittance advice, medical review sheet, medical records, and other correspondence
By Fax: 1(866)
By Mail: Aetna Better Health of Michigan
Attn: Provider Appeals
1333 Gratiot Avenue, Suite 400
Detroit, MI
Decision response
- Pre-service: within 35 calendar days
- Post service: within 35 calendar days
Appeal is reviewed by a physician not involved in original decision and not subordinate to original decision marker
The Appeal decision is the final decision
Member Appeals
Member authorization is required to appeal on behalf of a member (pre-service) 26

27. Questions?

28. Thank you