1. Doing Business with Aetna
Presenter: Wendy Guidera
AAHAM MD Chapter
November 16, 2012
<<Note to presenter>> This slide deck includes animation to complement the presentation. Be sure to view and present in slide show mode for optimal viewing.

2. Objectives At the end of this presentation you will be able to:
Contact Aetna
Identify our members and benefits plans
Navigate our secure provider website via NaviNet®
Registration/navigation
Transactions
Coding and account management tools
Educational Resources
And much more!!!
<<Note to Presenter - depending on the slide topics you choose, you may need to make changes to the objectives listed. You may remove slides as needed and add other slides from the self-service site. Please remember you may not edit the content of any slides. >>
During our presentation today we will talk about how to communicate with Aetna. I am sure most of you are aware of our dedicated provider service center and how to reach them via phone, but we talk about other ways to contact us and work more efficiently with us.
We will touch on how to identify our member and the different benefit plan types we offer.
We will spend the majority of our time today talking about our secure provider website which is supported by NaviNet. Our discussion will include how to register for and navigate the site, electronic transactions and tools to make it easier for you to do business with us.
I also want to spend a moment talking about our new education site for healthcare professionals.
<< Note to presenter - use this opportunity to tell the attendees how you would like to handle questions. You can address questions during the presentation or hold all questions until the end.>>
Doing Business with Aetna

3. Provider Service Center
Key Benefits to the Provider
Call operations
Claim operations
Self-service solutions
Complaints and appeals
Credentialing
Provider Data Services
At Aetna, we put the people who use our services at the center of everything we do and we live by a core set of values.
Today and everyday, you are at the center of our circle and that is the reason we have created a suite of dedicated provider resources and tools. We strive to simplify the provider experience. (tagline)
<<Note to presenter: The following information is very comprehensive. It is mainly available to prepare you for your presenation. There is no need to cover this level of detail for each category.>>
Doing Business with Aetna

4. Aetna at a Glance Key tools: Website registration and navigation
Transaction tips
Contact information
Regional information
<< Note to presenter – Be sure to share information about how to download a copy from the education site later on in the presentation. >>
We’ve designed this document to highlight the key tools we have created to enhance your provider experience.
It was initially created for newly credentialed physicians and hospitals to help get them started in doing business with Aetna. However, we have found even our established groups like this quick reference format.
The Aetna at a Glance gives you instructions for easy website registration, quick navigation and user-friendly tools and transactions to guide your provider experience. It also includes contact information such as important phone numbers and addresses. Lastly we have included a section for local or regional information such as special programs and any state regulations.
This resource should be shared with all of your office staff to simplify and ease your administration when working with Aetna.
Doing Business with Aetna

5. Aetna Benefits Products
Descriptive plan features:
PCP Selection
Referral guidelines
Benefit category
This booklet was designed to give you an overview of all of the different Aetna products as well as plan features. It was recently update to be a more user friendly document. Based on feedback directly from our provider office staff, this was changed to an easy to read grid format.
<<Note to Presenter>>
Be sure to mention later in the presentation where the booklet can be found on the secure site and the education site. (NaviNet/Resources and education site under reference tools)
Doing Business with Aetna

6. Aetna Benefits Products
As you can see, each plan is listed with PCP selection requirement, referral requirements and each plan is listed under the appropriate benefit category. You will also notice that appropriate dedicate provider service center phone is listed for each plan.
While each of our member ID cards are unique, you will find common characteristic on each card.
Doing Business with Aetna

7. Sample Member ID Card Product Name Referral Requirement
It is important to look to the product type in the upper right hand corner for the product name to determine how to work with the patient. The ID number is no longer an indicator of product type.
You will also notice referral requirements will be listed on the card.
There is a great reference tool and course available on our education site specifically designed to help you understand all the information on the ID cards.
Doing Business with Aetna

8. New Aetna Logo Doing Business with Aetna
<<Note to presenter>> It is not necessary to cover all of this information. The key point to the provider is the change in brand recognition on our ID cards and communications.
Aetna recently unveiled a refreshed brand promise as the company continues its evolution from an insurance carrier to a health solutions company. The most visible element of Aetna’s refreshed brand is a vibrant new look and logo – reflecting Aetna’s new vision to the marketplace. Far beyond a look or logo, the revitalization of the brand is focused on driving increased consumer engagement in their health care and empowering people to live healthier lives.
In case you haven't seen the new Aetna logo, we wanted to show it to you today.  You will begin seeing more of our new logo as we transition. 
Aetna’s face is changing- here’s why
You may have noticed our new look. We’re proud of our vibrant colors and bold logo. They capture our passion for building relationships with our members and providers like you. We’re continually changing to help our members feel confident in their health care decisions, and make it easier for them to live healthier.
Our new logo reflects this
Beginning this spring, be on the lookout for patients coming in with Aetna ID cards sporting our new logo. (During this transition, you can still accept ID cards with the old logo.)
Doing Business with Aetna

9. Aetna’s Secure Provider Website
As I mentioned, we are going to spend the majority of time today talking about our secure provider website which is supported by NaviNet. NaviNet is a free multi-payer website which allows you to not only access Aetna, but other payers as well.
If you have not yet registered, to get to this page, simply go to and click on the Health Care Professional tab at the top. You will see a link for “Secure Site Registration”. Once you are here, scroll down to the bottom and click on the “Sign-Up Now” button.
Doing Business with Aetna

10. Aetna’s Secure Provider Website
Contact:
If you are already registered for the site, this page looks for familiar to you as this is where you plug in your user name and password.
It is important to note that each office must identify a security officer, which is someone that will be responsible for maintaining the office (setting up new users, enabling and disabling transactions, etc). An office or facility may have more than one security officer. If you need additional assistance with registration, you can always contact NaviNet directly at
Now, let’s take a look at the site… Remember, since this is a multi-payer site, you will need to choose “Aetna” from the plan central home page!
Doing Business with Aetna

11. Aetna Plan Central Doing Business with Aetna
This is a screen shot of Aetna’s home page. Navigation is very easy and intuitive for this site.
A couple of key things to remember:
Across the top you will see the NaviNet Navigation Bar
Plan Central is where you can choose a Payor
Customer Support is NaviNet not Aetna support. Please contact them for any log in or navigational questions.
Gray Aetna Navigation Bars down left side
This is how you navigate to Aetna specific tools and transactions
The back browser button doesn’t always work in NaviNet. To navigate back, click on the white Aetna button at the top of the gray bars.
<Note to presenter: Mention some of the key areas listed in the menu.>
The Aetna Announcements section in the center
This is where you will find important information, outages, updates, etc.
The Resource Links down the right side
This is a list of frequently used areas of the website such as the Aetna Benefits Products booklet, the Precert Code Search tool, etc.
Doing Business with Aetna

12. Contact Us Doing Business with Aetna
You will notice on the top of a lot of the screen the Contact Aetna icon. This will allow you to communicate with us via !! A form will appear when you click on the icon.
is the most efficient method of contacting us.
Benefits
No long hold times
No need to take lengthy notes
Written documentation of response
Standard turn around time is usually hours however it is usually much faster.
Tips
Be sure to include TIN, name and address to prevent delay in hour response time
Be sure to select the right option
Provide as much information as we request in the drop down box
The entry box is free form with unlimited characters.
Doing Business with Aetna

13. Health Care Professional Toolkit
To access the toolkit, from the Aetna Plan Central home page, choose Aetna Support Center and then Doing Business with Aetna. You will scroll down to find the link for the toolkit.
Doing Business with Aetna

14. Health Care Professional Toolkit
The toolkit is set up much like our website… You will find all your content down the left side of the page. To see the information under each topic, just click on the “+” sign. The first time you enter the toolkit you will need to choose your region. Simply click on your state and it will tie you to the correct region.
The toolkit includes policies and guidelines for doing business with Aetna.
Doing Business with Aetna

15. Electronic Transactions
Provider
Aetna
Now let’s take a look at some of the electronic or real-time transactions that you can do right from our site. We strongly encourage these transactions to be done electronically to save you both time and money!
Even if you use another vendor for your claims, the NaviNet site is still an important Aetna resource for you. There are tools and transactions that are exclusive to the NaviNet site designed to make it easier to do business with Aetna.
Doing Business with Aetna

16. Eligibility Doing Business with Aetna
First, let’s take a look at the Eligibility & Benefits Inquiry. You’ll want to submit eligibility and benefits inquiries to obtain member plan details.
From the Aetna Plan Central home page, select Eligibility and then Eligibility and Benefit Inquiry. You can see that this is also where you would come to access Capitation and Member Roster if applicable to your practice type.
Doing Business with Aetna

17. Eligibility and Benefits Inquiry
Sample Provider – NPI #
The type of benefits you would like to see
A very simple and straight forward transaction…
There are a few simple fields to complete:
Requesting Provider is a drop down box of your providers based on your NaviNet registration (you may see a facility name, group name or individual providers listed)
Benefit type is the type of eligibility you would like to search. You can check general benefits or you can narrow down to a specific type of benefit.
Search Type is to let us know how you would like to search. If you have the member ID, go ahead and plug that in along with the date of birth. If you don’t have that, you can always search by last name, first name and date of birth.
Finally, enter the date of service. It will automatically default to the current date. You can search back up to 27 months, however you can not enter a future date as we can not guarantee eligibility in the future.
Click on search and your response will be returned on the screen.
Doing Business with Aetna

18. Eligibility Details Doing Business with Aetna
The response screen will give you great detail on the patient’s plan. Notice, if you searched by last name, first name and date of birth, one of the first fields you will see is the member ID. Other items include:
PCP requirements, if a PCP is required you will see who the current PCP is, their phone number and the effective date of that office.
Plan Name and Product type
Member demographic information
Eligibilty Status and Effective date of coverage
If the member has reported secondary insurance, you will see who the secondary carried is and information about that plan.
As you scroll down further or use the links at the top of the page, you will see the financial information, such as co-payment, health fund or HRA, deductible and co-insurance information. Keep in mind this is all real-time information and it is the same information you would get if you picked up the phone and called us directly.
In an effort to help determine the patients out of pocket cost at the time of service, we have launched a new tool to help you with this…
Doing Business with Aetna

19. Precertification Doing Business with Aetna
Another time saver is the on-line precertification process… You can submit admission requests, out-patient requests and even inquire to see if a precertification has been completed.
From the Aetna Plan Central home page, just select Precertification and then Precertification Submission or Inquiry
You will notice there is a link to our precertification list in the resources section along with a direct link to our precertification code search look up tool.
Doing Business with Aetna

20. Precertification Code Search Tool
This is the precertification code search look up tool.
You may enter up to 5 CPT codes at a time. You will get one of “3” responses. Yes, that’s right, one of “3”.
1. Yes, this service requires precertification through the Aetna website.
2. No, this service does not require precertification (if you need to print this for documentation, that is fine)
3. Yes, this service required precertification, however this is done through a delegated entity. This will happen when you enter one of the high-tech radiology codes, such as an MRI/MRA/CT or Nuclear Study. You will see a list of states and based on your state you will see the appropriate entity to contact (MedSolutions or CareCore). When you get this response, you will not need to complete the precertification request through Aetna.
Doing Business with Aetna

21. Precertification Doing Business with Aetna
Once you complete the member search, you will be brought to a screen to select the type of precertification you would like to complete (In-patient, Out-patient, Home Health, DME, Ambulance or Office). As you select the precertification you would like to complete, the fields at the bottom will be adjusted with the information needed.
Helpful Tip: Be certain to include your name and contact number where requested. If additional information is required, we will contact you directly.
You may also check status of a previously submitted precert request by accessing “Precertification Inquiry
Doing Business with Aetna

22. Precertification Form
Step 1
Step 2
Step 3
Step 4
Step 5
For this example, I have selected a Outpatient precertification. Step one is very important. In the event your precertification is pended for additional clinical information, we here at Aetna will contact you within 48 hours to gather the additional needed information. You can list yourself or anyone that might be responsible for providing clinical information (even a department).
Doing Business with Aetna

23. Referrals Doing Business with Aetna
We also offer referrals and referral inquiries from our site. From the Aetna Plan Central home page, select Referrals and either Referral Submission or Referral Inquiry.
Doing Business with Aetna

24. Referral Form Doing Business with Aetna Step 1 Step 2 Optional Step 3
The Referral Add transaction can only be used by PCPs and all referrals must be submitted electronically.  All Specialists visits, including visits in a hospital clinic, require a referral.
When submitting a referral, there are three options for selecting a refer to provider:
1. Using the link to DocFind®, our online provider referral directory.  This will allow you to find an individual physician's Provider Identification Number (PIN) or NPI.
2. You can build a list of frequently referred to specialist list,  which will create a drop down box for you.
3. The easiest and most efficient way is to refer the patient to a "specialty" instead of an individual "specialist" by using the taxonomy codes.  This will allow the patient to see any participating provider within that specialty.
Tips
Referrals should be issued using the Consultant and Treat code 99499
Referrals are valid for 1 year,  however the first visit must be used within 90 days
You can enter the number of visit need for treatment up to 99 visits 
Specialists can use the referral inquiry feature to see if a referral has been issued for a patient and what services have been authorized.
Step 4
Step 4
Optional Step 5
Doing Business with Aetna

25. Referral Inquiry Doing Business with Aetna
Sample Provider – NPI #
02/07/1981
Smith
John
As easy as it is for our primary care physicians to enter a referral our specialist can do a referral inquiry. It is no longer necessary for the primary care to fax, call or send the patient with a referral form. Specialist can inquire on those referrals issued directly to them or to their specialty code.
Doing Business with Aetna

26. Online Claims and Account Management Tools
For the billing staff or anyone that deals with claims and patients accounts we have a suite of tools to make your lives much easier!!
Doing Business with Aetna

27. Claims Doing Business with Aetna
Let’s start with claims… As you can see, there is lots of information under the claim section. We do strongly encourage all providers to submit their claims electronically. While most practice and facilities use a vendor for claims submission (using payer ID 60054) we do realize that some practices don’t. You can still submit your claims electronically by using our on-line claim submission. There are step by step instructions in the customer support section of the website.
Doing Business with Aetna

28. Claim Status Inquiry Doing Business with Aetna
Once a claim is accepted into the Aetna claim system, you may go online and check the status of the claim. The status provides claim and line-level detail. You may search using a 180 date of service span.
Doing Business with Aetna

29. Claim Status Inquiry Result
Once your response comes back, you can select the claim you would like review.
The claim status inquiry is great for looking up one single patient, however there may be times when you are looking for multiple patients or all your Aetna patients. For this, you will want to use the Claim Status Report. (next slide)
Doing Business with Aetna

30. Claim Status Report Multiple patients 90 days worth of claims
18 months from date of request
Semi-real time
Use this report to review of the status of claims associates with a specific provider for date range up to 90 days and not greater then 18 months from the date of the request. This is a semi-real time request. The request is submitted to Aetna when the search button on the request page is clicked. The response can take from a few hours to up to 12 hours to be returned. The user is not required to identify any member's.
This report can be found in your action items or by selecting claim status inquiry again from the menu and a download button will be available.
Caution: If claims for many Aetna patients are submitted under one TAX ID, then the response may include thousand of claims. Receiving too may claims can make it difficult for the user to navigate through the system to find the claim reports that are targeted by the user. If your TIN is associated with many providers, then use provider PIN numbers, or narrow the date range.
Doing Business with Aetna

31. Claims Status Report Result
Claim level detail
Line level detail
Sort by claim status (finalized, denied, in process)
This is an example of the report. The report currently reflects claim level detail only.
The Claim Status Report does not return detailed line level information. The user may request line level detail by selecting the gray box associated with the claim (no additional data entry is required). For claims that have been finalized the line level detail will show the patient responsibility.
The report can also be sorted by category by clicking on that header. (ex: Finalized, Denied, In Process)
This is a great tool to use when managing your accounts receivable.
Doing Business with Aetna

32. Claim EOB Tool Doing Business with Aetna
Our goal is to provide you with up-to-date information and technology for efficient and effective practice management. The Electronic Explanation of Benefits Tool—e.EOB is an account management tool that will allow hospitals, physicians and other health care providers to manage and review claims payments online. The EOB Tool is user friendly and it may help you operate with greater administrative ease, save time and money and make it simpler to do business with us. Please visit the Aetna education site for a brief tutorial and demonstration of the tool.
Doing Business with Aetna

33. Electronic Explanation of Benefits
XXXXX6789
You will want to decide on certain days of the week or every day to log in and check your daily EOB list.
When you sign up for Electronic EOBs, you’ll receive a daily EOB list, have the opportunity to search claims by member, provider, TIN/PIN combination and many other options that can make the business you do more efficient.
If you are signed up for EFT (electronic funds transfer), you will get an when a deposit has been made to your bank account. The will include the EFT trace number. You can take the EFT trace number and plug into the “search by payment” tab and pull all the EOBs associated with that payment. (this also works with a paper check number or even a dollar amount)
Doing Business with Aetna

34. Electronic Explanation of Benefits
Electronic EOBs are available in PDF format for review and printing. If you don’t have Adobe Acrobat Reader, we provide you with a link to a free download. It’s important to remember that these transactions are safe and secure. Only you may view claims payments made to your TIN.
The best thing about this tool is that you can submit a claim reconsideration right from this page. There is no need to call us, us or resubmit the claim.
<<Note to presenter>> The practitioner and provider appeals quick reference guide which defines reconsiderations vs. appeals can be found on the in the healthcare professionals section under policies and guidelines. Be sure to review this in advance as many provider offices tend to misunderstand the difference between reconsiderations and appeals. (appeals must be submitted in writing)
Doing Business with Aetna

35. Account Management Tool Claim History Report
The Claim History Report Request Form enables you to request a report of claims processed under your provider identification number for a specific date range for service or claim adjudication. This allows you to drill down on specific codes if needed.
Once your request has been submitted, you will receive a response within 24 hours.
This report can be found in your action items or by selecting claim history report again from the menu and a download button will be available.
Doing Business with Aetna

36. Account Management Tool Multiple Claim Reconsideration
This service is being provided to facilitate your analysis of claims that you suspect may have been reimbursed incorrectly. If, after reviewing the claim history report, you find there are 10 or more claims that you believe have been reimbursed incorrectly due to a common pricing or systemic issue, you can submit the corresponding Aetna Claim ID numbers.
Note: if you have fewer than 10 claims that need to be reprocessed, use the EOB tool. (reconsideration)
Doing Business with Aetna

37. Claim Policy and Code Editing Tools
Aetna offers several tools to assist you with accurate and appropriate coding practices. All of these tools are available on secure provider website via NaviNet. During the session I will share with you how and when to use:
Aetna’s Clinical Policy Bulletins (CPBs)
Clinical Policy Code Look-Up Tool
Clear Claim Connection Code Editing Tool
Payment and Coding Policies
Doing Business with Aetna

38. Clinical and Payment Policy Code Look Up
This tool allows you to search for CPT or HCPCS codes that may have limited or no benefits i.e. those considered cosmetic, experimental or investigational, based on Aetna’s standard clinical and payment policies. Where applicable, a direct link to our Clinical Policy Bulletins is provided.
If you enter a code such as an E&M code that doesn’t have a limited benefit, you will get a response of “sorry no matches are found”. That is because and E&M code typically doesn’t have a limitation.
This example shows HCPCS code K0005 – ultra-lightweight wheelchair.
As you know, wheelchairs aren’t covered for every situation.
You also have the option of searching by category:
Cosmetic
Experimental – Investigational
Incidental
Medically necessary
Never Effective
Doing Business with Aetna

39. Clinical and Payment Policy Code Look Up
If this procedure was never covered, the right-hand column would say “not covered” but it will always link you to an explanation why it is not covered.
If there are instances when the procedure may be covered, the right-hand column will offer the user a Clinical Policy Bulletin (CPB) to review or a link to a payment policy.
Note the date the web page was updated. In the event you are looking up a procedure done in the past, there may have been a change in policy.
Doing Business with Aetna

40. Code Editing Tool Doing Business with Aetna
The next Claim Payment Logic Tool is the Code Editing Tool. It is based on McKesson logic.
Use this tool to determine how code combinations billed together are likely to be adjudicated.
Although Gender and Age don’t generally impact payment, there are some situations in which the patient’s gender or age could impact the decision. For example: pediatric vs. adult codes, female related codes performed on a male, etc. Our recommendation is that you always enter the correct information to ensure the best outcome.
Enter CPT code and/or HCPCS code combinations along with any applicable modifiers. (note: you have the option to add more than 5 codes)
The diagnosis field is not required however the more information you provide, the more accurate your response will be.
Doing Business with Aetna

41. Code Editing Tool Doing Business with Aetna
This example reflects a series of hysterectomy related codes. The first code in this example is allowed at 100%. The secondary and tertiary codes indicate Disallow in red. This links you to the policy that supports the decision to disallow these procedures.
Doing Business with Aetna

42. Code Editing Tool Doing Business with Aetna
The response explains why there is no separate reimbursement for the secondary and tertiary codes in this example. Again, we will always provide rationale.
Doing Business with Aetna

43. Payment and Coding Policies
Another available link under Policy Information is Payment & Coding Policies
This section provides a comprehensive listing of our claim payment policies on a variety of subjects including anesthesia, modifiers, surgery, eligibility of an assistant surgeon, and various code specific logic.
Doing Business with Aetna

44. Payment and Coding Policies
The initial page displayed pulls up an alphabetical listing of the Payment & Coding Policies.
Doing Business with Aetna

45. Aetna’s Education Site for Health Care Professionals
Aetna offers a public education site for our health care professionals.
You will need to sign up with an individual name and password in order to get started. (no security administrator required)
This site was designed with you in mind. There are downloadable reference tools, self-paced courses (5-10 minutes in length) and free CMEs for clinical staff only.
There is also a book marking feature within the courses that allow you to pick up where you left off.
Select the course catalog to view the available courses.
To download copies of the Aetna at a Glance and the Aetna Benefits Products quick guide, refer to the reference tools section of the site.
Visit:
Doing Business with Aetna

46. Closing Key points from today’s session: How to contact Aetna
How to access secure provider website via NaviNet
Registration/navigation
Transactions – eligibility, precertification and Precertification Code Search Tool
Account Management Tools – claim status, Claim Status Report, eEOB and claim reconsiderations
Coding Tools – Clinical Policy Code Look Up, Code Editing Tool and claim and payment policies
Before we begin our Q&A session I would first like to acknowledge that we have covered quite a bit of information in a very short amount of time. The intent was to give you an overview of the different tools and transactions designed to make it easier than ever to do business with us. Remember to use the education site at as an additional resource if you need more in-depth information. And, the best way to learn is to jump in and give it a try!
Open for Q&A
Be sure to have each attendee complete a survey!
Doing Business with Aetna