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Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutionsReference guideHow to use Aetna’selectronic referralswww.aetna.com23.03.884.1 (1/15)
What you need to know about electronic referralsYou can request an electronic referral in real time for any planthat requires a referral. If you’re part of an independentpractice association (IPA), you should follow current referralprocedures for members in health maintenance organization(HMO) plans.If a plan requires a referral, one should be issued from theprimary care physician (PCP) for all specialist visits, includingvisits in a hospital clinic.Referrals aren’t required for direct access services, such asroutine eye care and ob/gyn services. Refer to the OfficeManual for Health Care Professionals located within the “HealthCare Professionals” pages on www.aetna.com for additionaldirect-access specialties in your area.A referral isn’t a substitute for a service that requiresprecertification. Visit www.aetnaelectronicprecert.comto check if a service requires precertification.To request a referral, you must be: A participating Aetna provider designated as a PCP--Note: The PCP making the referral must participate in themember’s benefits plan. A participating Ob/Gyn for certain services to specificspecialties--Note: This applies to HMO products only.Referrals may be issued to an individual specialist using his orher national provider identifier (NPI) or to a specialty using ataxonomy code. Use our DocFind online provider directory tofind a participating provider’s NPI. DocFind is located in themenu section of www.aetna.com/provider. For more onauthorizing a referral to a particular specialty using ataxonomy code, read on.Availability of our referral transactionsMonday – Saturday23 hours a day. Scheduleddowntime is 1 hour betweenmidnight and 5:30 a.m. ET.Sunday8 hours. We schedule routinemaintenance between midnightand 4 p.m. ET.You can find our electronic referral add and inquirytransactions on our free, secure provider website on NaviNet .To register, go to https://connect.navinet.net/enroll, andyou can log in at https://connect.navinet.net. Or you canfind these transactions on other participating websites.Find a list of participating websites atwww.aetna.com/provider/vendor.Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies (Aetna).22
Sending referral add requestsWe’ve included a list of required and optional information below. Enter all of the required information.Check with your vendor or clearinghouse for specific requirements.Referral entry — data requirementsRequired (R)Optional (O)Situational (S)CommentsMember IDRIf the member ID card is not available, you may perform aneligibility transaction to obtain the member ID. Due toprivacy concerns, we do not recommend using themember’s Social Security number.Requesting provider IDRMember date of birthSDependent statusRPatient first nameOService provider ID or taxonomy codeRPlace of serviceRNumber of visitsRDiagnosisOA diagnosis code isn’t required; however, it’s helpful for thespecialist.Procedure codeOIf you don’t give a procedure code, the referral will beauthorized for a consultation only. This includes automaticstudies.CommentsOIf member ID is not 8-digit alpha or alphanumericIf twins, tripletsYou don’t have to enter a procedure code for electronic referral transactions. Referrals submittedwithout a procedure code will default to a consultation only. If you enter a procedure code, you shoulduse either a CPT or HCPCS code. You may also input CPT code “99499” for “consult and treat.” Consultsinclude automatic studies.*We authorize referrals immediately. Elect Choice plan and Managed Choice plan referrals are valid forone year from the date when the referral was entered.* Automatic studies by specialty are services performed in a specialist office when patients are seen for visits and evaluations as aresult of our direct-access programs or when authorized by a referral from their PCP.3
How we handle referralsHMO referrals are valid for 90 days from the date entered.The first visit must be used within the first 90 days. After theinitial visit, any remaining authorized visits will expire oneyear from the original issue date. When we process the firstbilled service, an HMO referral is marked with one used visit.We then adjust the effective date to one year from thereferral effective date.The referral is available for use until it expires as describedabove or all visits are used — whichever comes first. Referralsfor Managed Choice and Elect Choice plan members are validfor one year from the original issue date.If you need to change any information on the existing referral,send a new referral request. You’ll get a new authorizationnumber and can give that to the member and/or thespecialist.In certain situations, you may see different information thanwhat you entered. For example, you’ll get a modified responsewhen capitation arrangements apply. If the provider to whomyou made the referral is not part of your capitationarrangement (for that specific specialty), then we willsubstitute a suitable provider. You’ll see this:“SPECIALTY CAPITATION ARRANGEMENTS MAY APPLYPLEASE CHECK TO SEE IF THE REFERRED TO PROVIDER ISPART OF THE CAP ARRANGEMENT FOR THIS REQUESTEDSERVICE”We won’t authorize referrals for services where we requireprecertification. For a list of services that requireprecertification, visit www.aetnaelectronicprecert.com.These requests will get the response: “Not Certified –Requires Medical Review,” along with the message: “THEPROCEDURE CODE SUBMITTED REQUIRES UTILIZATIONMANAGEMENT REVIEW. PLEASE SUBMIT THESE REQUESTSUSING THE PRECERTIFICATION TRANSACTION.” In someinstances, we’ll return consult and treat (99499) as a modifiedresponse for the procedure code that was rejected.For a list of possible error messages, please see below.Inquiring about submitted referral requestsYou can inquire about a specific referral by using theprevious review authorization number or by searching fora member/provider combination. We’ve included a list ofrequired and optional information you can include to searchfor a previously submitted referral request.Referral inquiry — data requirementsRequired (R)Optional (O)Situational (S)CommentsRequestingprovider IDRMember IDRDependentstatusRMember dateof birthSIf member ID is not8-digit alpha oralphanumericPatient firstnameOIf twins, ss of the plan type, when you inquire about apreviously authorized referral, we’ll tell you the numberof authorized and remaining visits. Inquiries for aprovider/member combination will return the five mostrecent referrals that match the criteria. Inquiries for aspecific referral will get information on that referral only.If additional referrals exist, they won’t be displayed on ageneral inquiry. Providers should contact Aetna’s ProviderService Centers to get details on the additional referrals. Ifyou have the certification ID, you should inquire electronicallyby performing a search for that specific number.4
Referrals using taxonomy codesAny participating provider can use the referral authorized to a taxonomy code for a particular specialty.Please note: Patients with certain benefits plans must see providers who belong to special networks.While it’s the patient’s responsibility to find a participating provider in their network, we’d like to makeyou aware of this requirement as well.The taxonomy codes listed on the following pages are HIPAA compliant. Referring physicians have theoption to refer electronically using either the specialist’s NPI or the taxonomy code for the specialty.Specialties are grouped by specialty family. All specialties in the family are assigned the same taxonomycode. For example, a referral can be authorized to Dr. Jones (cardiologist) using his NPI or using thetaxonomy code for cardiology, 207RC0000X. You must refer members to participating providers.Specialty familyAetna specialitiesTaxonomy codeALLERGY and IMMUNOLOGYAllergyAllergy (pediatric)ImmunologyImmunology (pediatric)207K00000XANESTHESIOLOGYAnesthesia (pain management)207L00000XCARDIOLOGYCardiac electrophysiologyCardiologyCardiology (invasive)Cardiology (pediatric)207RC0000XCARDIOVASCULAR andCARDIOTHORACICCardiothoracic surgeryCardiovascular surgeryPeripheral vascular diseaseThoracic surgeryVascular ive therapy111N00000XDERMATOLOGYDermatologyDermatology Diabetology (pediatric)EndocrinologyEndocrinology (pediatric)Metabolism and diabetesNutritional medicineNutritional medicine (bariatrician)NutritionistRegistered dietitianReproductive endocrinology207RE0101X5
Specialty familyAetna specialitiesTaxonomy codeGASTROENTEROLOGYColon and rectal surgeryGastroenterologyGastroenterology (pediatric)HepatologyProctology207RG0100XGENERAL PRACTICEAdolescent medicineDevelopmental medicineFamily practiceGeneral medicineGerontologyInternal medicineNurse practitioner (adult)Nurse practitioner (family practice)Nurse practitioner (geriatric)Nurse practitioner (pediatric)Pediatrics208D00000XGENETICSMedical genetics207SG0201XHEMATOLOGY and ONCOLOGYGynecologic oncologyHematologyHematology (pediatric)OncologyOncology (pediatric)207RH0003XINFECTIOUS DISEASEAIDSAIDS (pediatric)EpidemiologyInfectious diseaseInfectious disease (pediatric)207RI0200XINFUSION THERAPYInfusion EPHROLOGYHemodialysisHypertensive diseaseNephrologyNephrology (pediatric)207RN0300X6
Specialty familyAetna specialitiesTaxonomy codeNEUROLOGYNeurologyNeurology 0400XNEUROLOGICAL SURGERYNeurosurgeryNeurosurgery (pediatric)Neurosurgery (spine)207T00000XNUCLEAR RADIOLOGYNuclear medicineNuclear medicine (pediatric)2085N0904XOBSTETRICS and GYNECOLOGYAdolescent gynecologyGynecologyGynecologic oncologyInfertilityNurse midwiferyOb/gynObstetricsPerinatologyReproductive endocrinologyUrogynecologyVoluntary interruption of pregnancy207V00000XOPHTHAMOLOGYAnterior segment (glaucoma)Corneal specialistOphthalmologyOphthalmology (pediatric)Optometrist207W00000XORAL and MAXILLOFACIALSURGERYOral medicineOral surgeryOral surgery (pediatric)1223S0112XORTHOPEDICSHand surgeryOrthopedicsOrthopedics (foot and ankle)Orthopedics (joint replacement)Orthopedics (oncology)Orthopedics (pediatric)Orthopedics (spine)Sports medicineSports medicine (non-orthopedic)Surgery207X00000X7
Specialty familyAetna specialitiesTaxonomy logyOtolaryngology (allergy)Otolaryngology (head and neck)Otolaryngology (pediatric)Speech therapy207Y00000XPATHOLOGYLab workPathologyPathology (pediatric)207ZP0105XPEDIATRICSAdolescent medicineNurse practitioner (pediatric)Pediatrics208000000XPHYSICAL MEDICINE andREHABILITATIONHand rehabilitationOccupational medicineOccupational therapyPhysical medicinePhysical medicine and rehab(pediatric)Physical therapyRehab medicine208100000XPHYSICIAL THERAPYAcupunctureManipulative medicineManipulative therapyMassage therapyOccupational therapyPhysical therapy225100000XPLASTIC SURGERYCraniofacial surgeryCraniofacial surgery (pediatric)Oculoplastic surgeryPlastic surgeryPlastic surgery ULMONARY DISEASEHyperbaric medicinePulmonary diseasePulmonary disease (pediatric)Respiratory therapy207RP1001X8
Specialty familyAetna specialitiesTaxonomy codeRADIOLOGYMagnetic resonance imagingNuclear medicineNeuroradiologyRadiation oncologyRadiation oncology (pediatric)Radiation therapyRadiologyRadiology atology (pediatric)207RR0500XSLEEP DISORDERSleep disorder diagnostic261QS1200XSURGERYBreast surgeryColon and rectal surgeryGeneral surgeryOncologic surgeryPediatric surgeryProctology surgeryTransplant surgeryThoracic surgeryVascular surgery208600000XURGENT CAREUrgent care261QU0200XUROLOGYLithotripsyUrologyUrology (male infertility)Urology (pediatric)208800000X9
Referral status messagesHere is a list of potential status messages that may appear when a real-time referral add or inquiry is successful.Error messagePossible reasons for ionsReferring provider’s group ID is not designatedas primary.Resubmit with corrected information. Check listof allowed procedures for Ob/Gyn referrals.Referring provider not authorized to submitreferrals (not a PCP or Ob/Gyn).Resubmit using a “referred to” provider who isdesignated for Aexcel.Referring Ob/Gyn provider not authorized torefer for this procedure.Call the appropriate number below:Service (“referred to”) provider/specialty is notauthorized for Ob/Gyn referral.Service (“referred to”) provider is not adesignated Aexcel network provider for thespecialty requested.Certified in TotalTransaction was accepted and approved.Contact PayerThe member has behavioral health benefitsonly. 1 -888-MD AETNA (1-888-632-3862) forcalls related to indemnity and preferredprovider organization (PPO) plans 1-800-624-0756 for calls related toHMO plansCall the appropriate number as directed inthe message.Will be accompanied by this message:“BEHAVIORAL HEALTH BENEFITS ONLYCONTACT 800 424 4047”Duplicate Patient IDNumberMultiple members found, and uniqueselection search could not be made.Resubmit with patient’s first name.Call the appropriate number below: 1 -888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO-basedbenefits plans 1-800-624-0756 for calls related to HMO plansInput Errors for theService ProviderInvalid service (“referred to”) specialty’staxonomy value.Correct and resubmit.Call the appropriate number below: 1 -888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO plansInsufficient DataReceived To Identifythe Service ProviderService (“referred to”) provider NPI orspecialty’s taxonomy value missing.Providers must supply Aetna with their NPIbefore using their NPI in Aetna’s electronictransactions. Providers may supply their NPI tous on our website.Required ApplicationData MissingInvalid Place ofService CodeReview and complete entry of requiredinformation.Invalid place of service.Correct and resubmit.10
Error messagePossible reasons for errorResolution/actionInvalid/Missing Dateof BirthDate is not in valid format or date is invalid.Correct date or date format.Invalid/MissingPatient IDInvalid patient ID.Confirm zero vs. alpha O, 1 vs. alpha I.Confirm patient ID and resubmit.Invalid/MissingDiagnosis Code(s)Invalid diagnosis code.Correct diagnosis and resubmit.Invalid/MissingProcedure Code(s)Invalid procedure code.Invalid/MissingProviderIdentificationThe referring or service provider ID submittedwas missing, non-numeric or could not belocated during the provider search process.Verify provider identifier.The referring provider identifier submittedwas not an NPI. 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plansSubmission of ICD10 code before valid for use.Correct procedure and resubmit.Submission of ICD10 code before valid for use.If unable to resolve, call the appropriate numberbelow: 1-800-624-0756 for calls related to HMO plansModifiedTransaction was accepted, but some of thedata was modified in the request for theresponse.The requested referred-to provider does notalign with the specialty capitationarrangement that should be utilized by thereferring provider. A provider that does alignfor that specific specialty will be returned inthe response.Review the response carefully. In some cases,the requested referred-to provider or procedurecode was substituted with different values onthe response.In cases where a substitution could not beprocessed and capitation may exist, thefollowing message will be returned:“SPECIALTY CAPITATION ARRANGEMENTSMAY APPLY. PLEASE CHECK TO SEE IF THEREFERRED TO PROVIDER IS PART OF THE CAPARRANGEMENT FOR THIS REQUESTEDSERVICE”In some instances, a “consult and treat”(99499) will be returned as a “modified”response for a procedure code that wasrejected.11
Error messagePossible reasons for errorResolution/actionNo Action RequiredReferral not required for this member’sproduct/plan.Call the appropriate number below if plandiscrepancy is identified:Will be accompanied by this message: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO-basedbenefits plansCertification NotRequired for ThisServiceNo Prior Approval“MEMBERS PLAN DOES NOT REQUIREREFERRAL” 1-800-624-0756 for calls related toHMO-based benefits plansInvalid certification ID (referral number).Inquired-upon referral number is invalid.Correct certification ID (referral number) andresubmit.Will sometimes be accompanied by thismessage:Submit a general inquiry.“MEMBERS PLAN DOES NOT REQUIREREFERRAL”Not CertifiedAuthorization/AccessRestrictionsNot CertifiedRequires MedicalReviewThe procedures requested cannot be certifiedfor the specialty provider identified in thesame request.Will be accompanied by this message: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans“PROCEDURES MUST HAVE SAME SPECIALTY” 1-800-624-0756 for calls related to HMO plansThe services requested must be initiated usingthe precertification transaction and not thereferral transaction.Initiate a precertification transaction, or call theappropriate number below and select the optionfor precertification:Will be accompanied by this message: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans“THE PROCEDURE CODE SUBMITTEDREQUIRES UTILIZATION MANAGEMENTREVIEW PLEASE SUBMIT THESE REQUESTSUSING THE PRECERTIFICATIONTRANSACTION”Not CertifiedServices were notconsidered due toother errors in therequest.Call the appropriate number below if plandiscrepancy is identified:There were other errors returned in theresponse. 1-800-624-0756 for calls related to HMO plansReview the entire transaction response to findthe root cause of why the request was rejected.12
Error messagePossible reasons for errorResolution/actionOut of NetworkService provider is nonparticipating.Resubmit with corrected information.Referring provider is nonparticipating.Potential work-around for issues with service(referred-to) providers that enumerated with thesame NPI is to submit a specialty referral(taxonomy code) instead of using an NPI.Referring or service provider is not contractedin member’s product.Call the appropriate number below: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO plansPatient Not EligibleMember coverage terminated or not yetactive.No active medical products were found.Verify member ID is correct.Call the appropriate number below to verifycoverage: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO plansPatient Not FoundNo member found for member numbersubmitted.Verify member ID, correct and resubmit. Ifmember ID is correct, call the appropriatenumber below: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO plansProvider Is Not aPrimary CarePhysicianThe referring provider ID submitted is not aprimary care physician.Verify provider identifier.Call the appropriate number below: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO plansSubscriber Found,Patient Not FoundThe subscriber ID was found, but nodependent matched the submitted patientdate of birth.Patient could be subscriber, not dependent.Verify member ID number.Confirm relationship to subscriber and patientdate of birth.Correct and resubmit.If member ID, relationship and date of birth arecorrect, call the appropriate number below: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO plans13
Error messagePossible reasons for errorResolution/actionUnable To Respond atThis TimeSystem unavailable — scheduledmaintenance being performed.Attempt transaction at a later time.Unplanned communication outage.Internal system processing errors.For outages greater than 30 minutes, contactthe vendor help desk for estimated time ofavailability.When resubmission not allowed, call theappropriate number below: 1-888-MD AETNA (1-888-632-3862) forcalls related to indemnity and PPO plans 1-800-624-0756 for calls related to HMO planswww.aetna.com 2015 Aetna Inc.23.03.884.1 (1/15)
The taxonomy codes listed on the following pages are HIPAA compliant. Referring physicians have the . Physical therapy Rehab medicine 208100000X PHYSICIAL THERAPY Acupuncture Manipulative medicine Manipulative therapy Massage therapy Occupational therapy Physical therapy 225100000X PLASTIC SURGERY Craniofacial surgery
