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Aetna Better Health of OhioDual Preferred (HMO SNP)Providertraining 2018Aetna Inc.ProprietaryJanuary 20181

Training Outline Aetna Better Health of Ohio plan overview Supplemental benefits Prior authorization (PA) requirements Claims submission Participating provider disputes Provider responsibilities Cultural competency Secure provider portal Contacts and resourcesCONFIDENTIALdProprietary2

Overview

Aetna Better Health of Ohio Dual Preferred (HMO SNP)What is it?Aetna Better Health of Ohio Dual Preferred (HMO SNP) is a Medicare plan offered to dual-eligibleindividuals in select counties in Ohio.Aetna MedicaidProprietary4

What is a DSNP?SNPs (Special Needs Plan) are benefit plans customer designed to meet the needs of specific groupsof members with special healthcare needs.The DSNP is available to eligible members: Residing within the program’s service area. Meeting dual-eligibility status requirements.In many states, we’ll enroll partial-benefit duals as well as full-benefit duals.For this plan, we are accepting two partial-dual populations: Qualified Medicare Beneficiaries (QMB)and Qualified Disabled Working Individuals (QDWI) and three full-dual populations: Qualified MedicareBeneficiary Plus Medicaid (QMB ), Specified Low-income Medicare Beneficiary Plus Medicaid (SLMB )and Full Benefit Dual Eligible (FBDE).Dual Eligibility qualifications is determined by the member’s enrollment in: A federally administered Medicare program based on age and/or disability status. The state-administered Medicaid program based on low income and assets.ProprietaryAetna Medicaid5

Aetna Better Health of Ohio Dual Preferred (HMO SNP)A Duals Special Needs Plan (DSNP) is a type of Medicare Advantage plan for dual-eligible individuals.Aetna MedicaidProprietary6

Medicare Advantage (MA) plansThis particular Medicare Advantage plan is a Medicare Advantage Prescription Drug (MAPD) plan.Part CAdvantage plansPart AInpatient servicesPart BOutpatient servicesPart DPrescription drugsSupplemental benefitsMedicaid services — not covered through this DNSPAetna MedicaidProprietary7

Part A covered services: “Hospital insurance”Inpatient carein a hospital 2017 Aetna Inc.ProprietaryInpatient carein a skillednursing facility(SNF)Hospice careHome health8

Part B covered services: “Medical insurance”There are numerous Part B covered services. The complete list may be found in theMedicare and You handbook.PreventativeServices(cancerscreenings, flushots) 2017 Aetna Inc.ProprietaryDiabetessupplies(testing hairs,walkers)Lab services(blood tests,tissue specimen)9

Member ID CardInformation on the Dual Preferred member ID card can help you file claims more efficiently and accurately.Be sure to obtain a copy of the member ID card, as well as their Medicaid ID card for your files.The member ID card also contains information pharmacies will need to fill prescriptions.Providers should remind patients to bring both their Dual Preferred ID card and their Medicaid ID to thepharmacy when they have a prescription filled. 2017 Aetna Inc.Proprietary10

Member EligibilityDual-eligibilityBased on age, financial resources and disability status.Medicare Must maintain Medicareeligibility based off age ordisability.Aetna MedicaidProprietaryMedicaidMust maintain Medicaideligibility in their state ofprimary residence.11

Member Eligibility (cont’d)Dual eligibilityAs a reminder, there are different types of dual-eligibility.Aetna Better Health of Ohio Dual Preferred (HMO SNP) accepts three styles of full-benefit dual eligibility and twostyles of partial-benefit dual eligibility.Full benefitdual eligibleMedicare cost-share protectionand full Medicaid benefitsPartial benefitdual eligibleMedicare cost-share protectiononly (no Medicaid benefits)Aetna MedicaidProprietaryQMB Plus: Qualified Medicarebeneficiaries with full MedicaidFBDE : Full benefit dual withSLMB Plus: Specified low-income Medicare beneficiarieswith full MedicaidMedicaidQMB-only: QualifiedMedicare beneficiaryQDWI*: Qualified disabledand working individuals*not fully protected fromMedicare costs12

Member Eligibility (cont’d)Service area-based eligibility11 counties in the Northwest (Toledo) andNortheast regions (Youngstown and Akron areas)NorthwestNortheast Fulton Wayne Lucas Summit Ottawa Stark Wood Portage Trumball Mahoning ColumbianaAetna MedicaidProprietary13

Enrollment TimelineWhen is it happening?October 15, 2018Open enrollment began.Eligible beneficiaries allowed to sign up for the plan.January 1, 2019Coverage year (CY) 2019 benefits became effective for allactive enrollees.Aetna MedicaidProprietary14

Important Plan Details This is a health maintenance organization (HMO) plan. Providers who are already contracted with Aetna Medicare HMO will also be a provider for this DSNP. There are 13 supplemental benefits offered by this plan.Aetna MedicaidProprietary15

Supplemental benefits

Supplemental me DeliveredMealsPodiatryVendorHearing CareSolutionsLogisticareDentaQuestVSP Vision CareGA FoodsAetnaCoverage1 routine exam, 1fitting, 500 perear for hearingaids24 one-way tripsto approvedlocations 1000 Maxbenefit forpreventative andcomprehensivecare1 routine exam, 250 to usetowards contacts,glasses andframes14 meals over 7days delivered toenrollees homeafter discharge3 visits by innetwork providerOnly valid afterinpatientdischarge from ahospital.20% coinsurancefor this benefit.Check withMedicaid plan forcost pick up.Important NotesAetna MedicaidProprietary17

Supplemental Benefits (cont’d)FitnessMembershipOTC AssistanceSmokingCessationHealthEducationRemote eOutpatientBlood ServicesVendorSilver e access toapproved gymsand fitnessclasses 55 per monthtowardapproved OTCmedicationsSmokingcessationproducts andservicesInformation forresources tomembers for ahealthierlifestyle.Nurse Hotlineavailable 24hours a day, 7days a week80% coverageby this plan forEmergencycare in foreigncountry.Waivesdeductibleassociated withthe first 3 pintsof bloodreceived.This moneydoes not rollover eachmonthNicotinereplacementtherapy (NRT)products arenot covered aspart of this.ImportantNotesAetna MedicaidProprietary20%coinsurance.ConsultMedicaid forfurthercoverage18

PriorAuthorizations 2018 Aetna Inc.Proprietary1919

Prior Authorization OverviewProviders are responsible for complying with Aetna’s prior authorization (PA) requirements, policiesand request procedures as well as for obtaining an authorization number to be reported on theirclaims.A list of services that require prior authorization can be found on our website atwww.aetnabetterhealth.com/ohio-hmosnp/The Secure Provider Portal Authorization Tool gives providers the ability to Search PA requirements by individual or multiple Current Procedural Terminology/ Healthcare CommonProcedure Coding System (CPT/HCPCS) codes simultaneously. Review PA requirements by specific procedures or service groups. Receive immediate details as to whether the codes are valid, expired, a covered benefit, have PA requirements,and any noted PA exception information. Export CPT/HCPS code results and information to Excel. AetnaEnsuresstaff works from the most up‐to‐date information on current PA requirementsMedicaidProprietary20

Prior Authorization Search ToolThe “PA Requirement Search Tool” is used to determine if prior authorization (PA) is required.Authorizations must be obtained in advance of services being provided.Enter up to six CPT/HCPCS codes or a CPT group and select SEARCH.Aetna MedicaidProprietary21

Prior Authorization Search ToolSearch result definitionsYES - Prior authorization request is required for this service.NO - Health plan does not require a prior authorization request for this service.NON-COV - CPT or HCPCS code entered is not a covered benefit by health plan.INVALID - CPT or HCPCS code entered was invalid, not found.EXPIRED - CPT or HCPCS code entered is no longer valid for use by health plan providers.Aetna MedicaidProprietary22

How to Request a Prior AuthorizationA prior authorization request may be submitted in one of three ways1. Submitting the request through the 24‐hours‐a‐day, 7‐days‐a-week Secure Provider Web Portal located on ourwebsite (only available to contracted providers)2. Faxing the request form to 1‐866-742-7210 (form is available on our website). Please use a cover sheet withthe practice’s correct phone and fax numbers to safeguard the protected health information and facilitateprocessing.3. Calling us directly at 1-800-260-3166.Other helpful informationDSNP UM/FAX LinesAetna MedicaidProprietaryToll FaxnumberToll Free FaxNumberOH DSNP IP/ConcurrentReview959-282-8789866-742-7209OH DSNP NOMNC959-282-8801866-392-766223

ClaimsSubmission 2018Aetna MedicaidAetna Inc.Proprietary24

How to BillA claim may be submitted in one of three ways1. Electronic claims through provider’s own clearinghouse. Before submitting a claim through your clearinghouse, please ensure that your clearinghouseis compatible with Change Healthcare, using the 837 file format. Please use Submitter ID #50023 when submitting electronic claims.2. Electronic claims through ABHO Provider Portal (Change Healthcare) Aetna Better Health of Ohio encourages participating providers to electronically submit claimsthrough our portal at www.aetnabetterhealth.com/ohio-hmosnp/, select “For Providers”, then‘’Claims’ tab”, “How to File a Claim”, then link to “WebConnect” on the page.3. Paper claims Mail toAetna MedicaidProprietaryAetna Better Health of Ohio Dual Preferred (HMO-SNP)PO Box 64205Phoenix, AZ 8508225

Claims Submission TimeframesTo best ensure timely and accurate payment of your claim, submit a “clean claim”.A “clean claim” is a claim that can be processed without obtaining additional information from the provider ofa service or from a third party.Clean claims are processed according to the following timeframes: 90% of clean EDI claims adjudicated within 30 days of receipt 99% of clean paper claims adjudicated within 90 days of receiptTimely filing of claim submissions In accordance with contractual obligations, claims for services provided to an enrollee must be received ina timely manner. Our timely filing limitations are as follows:o New Claim Submissions –Please consult your contract for your contractual timely filing limit for newclaims.o Claim Disputes & Resubmissions – Please consult your contract for your contractual timely filing limit fordisputes and corrected claims.Failure to submit claims and encounter data within the prescribed time period may result in paymentdelay and/or denialAetna Medicaid Proprietary26

Claims Submission Nomenclature Claim numbers are assigned using the year and then the Julian date. For example, 19001 at the beginning of a claim would indicate that claim was receivedon the First day of 2019. A claim beginning with 19365 would indicate that claim was received on the last day of2019. Claim Indicators: “R” indicates a reversal of a claim and proceeds the adjustment (if applicable) of theclaim. The number following “R” represents the number of times the claim has beenreversed.- Example: 19001E999999R1 “A” indicates an adjusted claim and follows the original claim number. This claim iscreated after the reversal of the original claim. The number following “A” representsthe number of times the claim has been reprocessed.- Example: 19001E999999A1Aetna MedicaidProprietary27

ParticipatingProviderDisputes 2018Aetna MedicaidAetna Inc.Proprietary28

Dispute Process for Contracted ProvidersAs a contracted provider, if you disagree with a claim decision AetnaBetter Health of Ohio Dual Preferred (HMO-SNP) has made, thereare two options:1. Use the Secure Web Portal to dispute the claim electronicallyafter locating the claims on the right.2. Fill out and return the Provider Dispute form and mail to our PObox.Aetna MedicaidProprietary29