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Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutionsOctober 2016 AAHAM UpdatesDebby SynowickiSr. Provider Relations Representative
Aetna’s Values Wheel2
Aetna & Coventry NewslettersStay up to date with quarterly newslettersAetna OfficeLink Updates Located on www.aetna.com Health Care Professionals Newsletters andNews. Sign up to have delivered right to your email.Coventry Provider News Located within the “News” section of www.directprovider.com orwww.chcnebraska.com Services & Support Providers,Announcements/News. The October 2016 edition will be the last Coventry Provider News. Pastcopies will be located on the website for history purposes.3
Provider Office ManualsAetna and Coventry’s provider office manuals are available on ourwebsites and keep you informedAetna provider office manual Aetna.com Health Care Professionals Education & Manuals Exploreprovider manuals Navinet.net Aetna Health Plan ResourcesCoventry provider office manual chcnebraka.com Providers Document Library CommercialGuides/Manuals4
CredentialingAetna uses CAQH to credentialing providers Providers should go to aetna.com Health Care Professionals Join the Network–– If already registered with CAQH, provide the CAQH number when completing the join the networkinformationIf you have not registered with CAQH, you will receive a registration kit 7-10 days after submittingyour online Aetna application.Credentialing with Aetna, completes credentialing for Aetna, Coventry, Aenta and CoventryWorkers’ Comp, Auto, Aetna Signature Administrators and First Health.Once credentialing is complete, you will receive a notification letter and/or a contract (ifneeded).Once credentialing and contracting are complete, an effective date will be assigned.Questions about participation 1-888-MD-Aetna (1-888-632-3862)Check status of credentialing 1-800-353-1232For additional information, please go to - care-professionals-join-network.html
Aetna and Coventry PlansCommercial group POS and PPO employer planssold in all counties of Nebraska.National PPO employer plans sold inall counties in Nebraska and as a wrapnetwork to Coventry plans who havemembers residing outside of theirlocal network areas.Commercial group POS and PPOemployer plans sold in all counties ofNebraska. Commercial plans will becontinuing to transition from Coventryto Aetna through mid 2017.6
Individual & Small Group Plans for 2016This is an individual Coventry Health Care plan. A fullnetwork POS (point of service) option was sold on theMarketplace Exchange. This product was offered tomembers in all counties except – Douglas and Sarpy.This product will no longer be offered in 2017.This is an individual & small group Coventry Health Care plan.The Carelink logo means that this is a limited network plan.These plans were offered to members only in Douglas, Sarpy andPottawattamie counties. These plans will no longer be offered in2017. Aetna Leap plans will be offered.Carelink from CoventryOne - CHI HealthCarelink from CoventryOne – Nebraska Health NetworkCarelink from CoventryOne – Methodist Health PartnersCarelink from CoventryOne - MIPPA7
Individual & Small Group Plans for 2017This is a small group Aetna ACO narrow network plan.These plans are offered to members only in Douglas,Sarpy and Pottawattamie counties. This product will beoffered in 2017.Aetna Leap This is an individual & small group Aetna plan. Limitednetwork Aetna Leap plans will be identified in thenetwork name on the member ID card. Limitednetwork plans will be availble beginning 1/1/17 tomembers in Douglas, Sarpy & Pottawattamie counties.Aetna Leap - CHI Health OmahaAetna Leap - MIPPAAetna Leap - Nebraska Health NetworkThis is an HMOproductAetna Leap - BroadIndividual and small group plans available in allNebraska Counties outside of Douglas and Sarpy areoffered a full provider network.
Rental Network PlansAetna & Coventry’s rental networks. These are networks that various payersaccess.Attached is a listing of payers accessing the ASA network. For a listing of payersaccessing the First Health Network, please log into directprovider.com.As a reminder, you should send all claims for ASA and First Health Networkmembers electronically to the payer ID listed on the member’s ID card. Sendpaper claims only to the address listed on the ID card.Direct all ASA and First Health Network claim questions to the appropriate payeron the ID card.9
Medicare Advantage PlansCoventry and Aetna both have Medicare Advantage Plans.Coventry Advantage plans are sold in Douglas, Sarpy, Cass, Otoe, Gage,Jefferson, Lancaster, Washington, Seward, Butler, Colfax, Dodge, Cuming,Burt & Wayne counties. Coventry Advantage plans will be available tomembers through 12/31/17 and no longer available as of 1/1/2018.Aetna Medicare is currently available to employers as retiree coverage.Aetna Medicare will be available to all Medicare Advantage members in1/1/2018.10
Help members save by staying in networkOpen enrollment is coming and existing patients may call in with questions aboutparticipation with certain plans.Check your participation statusAetna Provider Search - Docfind Aetna.com Find a Doctor Select the members’ plan within your searchCoventry Provider Search chcnebraska.com Find a Doctor Enter provider search Select the members’ planWhen referrals are recommended for a consult/procedure, refer members within theirspecific networks. Also, please make sure that your practice is in network with the membersplan prior to seeing the member. Many members have limited provider networks and mayhave to pay more if they go out of network.See attached handout for additional search instructions11
Digital Aetna Member ID CardsWhat you need to know about digital member ID cardsWhy go digital? Digital ID cards are accurate and up to date. They’re a more secure source of benefits information. Producing less plastics helps our environment.How can you get a copy of the ID card? NaviNet allows your office to search with out the member ID number andobtain a copy of the most current member ID card.Please see attached handout for additional information and instructions12
National Precertification List (NPL)Aetna and Coventry have one participating providerprecertification list as of April 1, 2016 NPL can be found on both aetna.com and chcnebraska.com. Please check the appropriate NPL for the either Coventry or Aetna, fordirection to the appropriate phone numbers, fax or vendor.Updates for 10/1/16 - Services no longer requiring precertification Dialysis services at participating facilities Cochlear implant replacement items Ventricular Assist Device replacement supplies and accessories Following drugs/medical injectables– Aloxi IV, Anzemet IV, Jevtana, Aredia, Boniva, Reclast and ZometaFor a full listing of all updates and changes please visit view the September2016 Aetna Office Link Update13
PharmacyChanges to our commercial drug lists begin on January 1, 2017On January 1, 2017, our pharmacy plan drug lists (formulary) will change. Starting on September1, 2016, you can view these changes on our Guides for prescription drug coverage web pagelocated on aetna.com.The changes may affect: All 2017 Pharmacy Management drug lists Precertification program Quantity limits program Step-therapy programThree ways to request a drug precertification: 1. Call the Aetna Pharmacy Precertification unit at 1-800-414-2386. 2. Fax your completed prior authorization request form to 1-877-269-9916. 3. Submit your completed form through NaviNet. For more information call us at 1-800-238-6279 (1-800-AETNA RX).
Specialty Drugs & FormulariesSpecialty drugs — precertification update For pharmacy covered specialty drugs on the National Precertification List (NPL), we’veupdated our contact information for making your requests. Beginning October 1, 2016,you can reach us in either of the following ways:Call the Aetna Pharmacy Precertification Unit at 1-855-240-0535.Fax the completed Specialty Pharmacy Precertification request form to 1-877-269-9916.New fax forms are located in the Specialty Pharmacy Precertification section of our Find aform web page on www.aetna.com.Where to find our Medicare and commercial formularies At least annually, and from time to time throughout the year, we update the AetnaMedicare and commercial (non-Medicare) Preferred Drug Lists. These drug lists are alsoknown as our formularies.To find them, go:Aetna.com/Healthcare Professionals/Medicare/Find Prescription Drug InformationAetna.com/Individuals & Families/Find a MedicationFor a paper copy of these lists, call the Aetna Pharmacy Management Provider HelpLine at 1-800-AETNA RX (1-800-238-6279).
Clinical Policy BulletinsAetna and Coventry both use Aetna’s Clinical Policy BulletinsMedical Clinical Policy Bulletins (CPBs) detail the services and procedures weconsider medically necessary, cosmetic, or experimental and unproven.View medical and pharmacy Clinical Policy Bulletins (CPBs) online throughaetna.com or NaviNet: Aetna.com Health Care Professional Clinical Policy Bulletins NaviNet.net Aetna Health Plan Resources Clinical Policy Bulletins16
Payment PoliciesClinical payment, coding and policy changesPlease view the most current Coventry Provider News and Aetna Office LinkUpdate for a listing of upcoming payment policy changes.View policy information on NaviNetMy Health Plans Aetna Health Plan Select Claims Policy Information Claims tools for code editing Payment policies look up Payment and coding policies
Aetna Code Editing, Clinical & PaymentPolicy Lookup ToolUse the Clear ClaimConnection toolto determine how asingle code or codingcombinations (CPT andHCPCS) may beprocessed.Use this tool to determine: How multiple procedures may be processed If a procedure has limited benefits (forexample, cosmetic surgery or experimental orinvestigational treatments) How modifiers are handled18
Timely Notification for ObservationAetna and Coventry will not be implementing the Timely Notificationpenalty for Observation stays. If an authorization for Observation over 24hours is not obtained, the claim will be denied for no authorization.19
Disputes, Reconsiderations & AppealsFor additional information on time frames, turn around times, additionallevels of appeal or reconsideration, forms or need to know where to senddisputes, reconsiderations or appeals please visit –www.aetna.com Health Care Professionals Dispute & Appeals Processwww.chcnebraska.com Services & Support Providers DocumentLibrary Provider Manual20
Dispute, Reconsideration & Appeals FormsForms for disputes, reconsiderations and appeals can be foundwith the following paths Aetna Formswww.aetna.com Health Care Professionals Disputes & Appeals Finddispute and appeal formsCoventry Formswww.chcnebraska.com Services & Support Providers Document Library
Aetna Provider Service ModelAetna and Coventry would like to remind providers to use the Provider Service Center as afirst point of contact for claim issues and questions.Many providers have not been using this method and reaching out directly to ProviderRelations. Aetna has begun to reject requests for reprocessing or review of a claim at therequest of provider relations; if the provider has not reached out to the service center first.Tips for claims resolution – Providers should call the Provider Service Center (PSC) or submit an inquiry through NaviNet for Aetnaplans and Directprovider.com for Coventry plans.When talking to a customer service representative in the PSC, please request the claim to be submitted forreprocessing/review. If just checking the claims status the rep will not send the claim through forreprocessing without a request.If providers feel they are not getting the answer from the representative, then please ask for asupervisor. If communicating via secure messaging through the provider portals, please request asupervisor reach out to you and provide your phone number.Write down all reference numbers and names.If after speaking to a customer service representative and supervisor does not correct the issue, thenplease reach out to Provider Relations and provide reference numbers.Providing the reference numbers and names will help Aetna provide education and track trendingissues.
2016 Medicare AttestationComplete your 2016 Medicare compliance attestationAnnual requirementEach year you must confirm you’ve met the Medicare compliance program requirements bycompleting an attestation. One attestation meets both Aetna and Coventry complianceobligations. Not complying could impact your participation status.The attestation is now available on our secure provider website. If you’ve never used NaviNet, login or register today: Once you log in, go to Aetna Health Plan. Go to “Compliance Reporting” (on the left) and thenclick “Medicare Attestation.”We’re here to helpIf you need more information, you can find educational content on www.aetnaeducation.com bytyping “FDR” in the search box. Or you can call 1-800-624-0756.Disregard this notice if you have completed your 2016 Attestation.
Provider Demographic InformationHow to update data about your office To update your office’s demographic information, log on to NaviNet. Pleasesee attached guide for additional instructions on what type of updates areimportant to update. If you’ve been calling our Provider Service Center to make these changes,we ask you to use the secure site instead. The site lets you confirm theinformation you submit. It prevents unauthorized individuals fromsubmitting wrong information about your office or facility. The Centers for Medicare & Medicaid Services (CMS) requires MedicareAdvantage plans and Qualified Health Plans (QHPs) to maintain accuratedirectories. Having your up-to-date information allows us to do that.See handout for additional information.24
Coventry Trainings – chcnebraska.com
Aetna Learning Opportunities26
2016 NaviNet Basic Live WebinarsJoin us for a free webinarDuring this one-hour session, we’ll demonstrate how to: Register for and navigate our secure provider website supported by NaviNet Identify the role and responsibility of the NaviNet security officerComplete real-time transactions, including:--Eligibility--Payment Estimator--Precertification (including our Precertification Code Search Tool)Access our suite of account management tools:--Claims status inquiry/claims status report--Electronic Explanation of Benefits (including claims reconsiderations)Locate our claims payment and coding resources:--Code Editing, Clinical & Payment Policy Lookup tool--Payment and coding policiesYou’ll also have time to ask questions about how you can use these tools in your office or facility.See attached handout for Webinar session dates and how to register!
Thank you
This is an individual & small group Coventry Health Care plan. The Carelink logo means that this is a limited network plan. These plans were offered to members only in Douglas, Sarpy and Pottawattamie counties. These plans will no longer be offered in 2017. Aetna Leap plans will be offered. Carelink from CoventryOne - CHI Health Carelink from CoventryOne - Nebraska Health Network Carelink .
