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At a glanceA how-to guide for health careprofessionals who work with us83.03.830.1 O (12/20)

Knowing whatto do makeseverything easier.Aetna is the brand name used for products and services provided by one or more of the Aetna group ofcompanies, including Aetna Life Insurance Company and its affiliates (Aetna).2

Table of contentsHelpful provider website4Think webinars can’t be cool?12Clinical and office support5Northeast region13Tools and transactions6Mid-America region15Claims how-to8Southeast region17West region19Contact us103

Helpful provider websiteDoing business with us onlineNeed help?Use Availity.com, our provider website, to save time.This is a free, multipayer, web-based system foradministrative transactions. You can use the toolsand resources available on Availity to quickly accessthe information you need.For registration questions or log-in or password help,call 1-800-Availity (1-800-282-4548) Monday throughFriday, 8 AM to 7 PM ET.Access your provider account Go to Availity.com, our provider website. Select “LOGIN.”Register on our provider websiteFirst, gather the information below. You’ll need itto register successfully. Tax identification number (TIN) Physician name, group name or hospital name Email addressAvaility offers many helpful online support tools: On-screen help to walk you through each stepof a transaction Step-by-step transaction and user guides Online training demonstrationsImportant announcementsOn Availity.com, visit the Aetna Payer Space homepage to get time-sensitive information. Be sure to visitoften — the information shared may affect how you dobusiness with us. Primary office locationOnce you have that information ready, then: Go to Availity.com. Select “REGISTER.”Website administratorYou must designate an administrator for your office,and that person must be the first person to registeron Availity. That’s because the first person to registeris given site privileges to administer all functions andmanage access for other users.Each user needs their own credentials. Sharing user IDsisn’t allowed.Have the designated administrator log in first onAvaility.com by selecting the green “LOGIN” button.Visit Availity.com/aetnaproviders to learn more.If users can’t access some of the tools on Availity, pleasecontact your administrator. There are some transactionsthat the administrator must enable.4

Clinical and off ice supportTools and resourcesHelpful guidesOn Availity, to see a list of commonly used tools andresources, go to the “Aetna Payer Space” and selectthe “Resource” tab. Aetna Benefits Products — an easy-to-use guidethat provides basic benefits product information,including primary care physician (PCP) selection andreferral requirements.There, you’ll find: The Precertification Code Search tool, which makesthe precertification process easier. Our Clinical Policy Bulletins, which are detailed andtechnical documents. They explain how we makecoverage decisions for members under our healthbenefits plans.Clinical resources Aetna Health ConnectionsSM Disease Managementprograms, which provide educational materials and,in some cases, individualized case management formembers with chronic health conditions. The programsfocus on health education and behavior modification formodifiable risks. Aetna Office Manual for Health CareProfessionals — your guide to working with us.This reference tool acts as our provider manual,and it includes local information that pertains toyour practice. Our Member Rights and Responsibilitiesare also included in the manual.Pharmacy Formulary information Pharmacy clinical policy bulletins E-prescribing Aetna Women’s HealthSM programs and policiesprovide detailed information about our gynecologicand obstetric programs and policies. This includesinformation on the Aetna Maternity Program, Infertilityprogram and Breast Cancer Gene (BRCA) GeneticTesting Program.5

Tools and transactionsEligibilityClaimsUse the Eligibility and Benefits Inquiry transaction toget member-specific plan details. Transaction responsefields (which may vary according to plan details) include:We offer a wide variety of tools to help you manageyour patient accounts: Copay, deductible and coinsurance Professional claims submission (including Aetna secondary claims) Exclusions and limitations Claims status (checking the status of one single patient) Visits used and visits remaining Claims Status Report (checking the status of all yourpatients within a date range) Referral and precertification requirements Ability to view and print digital member ID cards*Here are some tips for completing the fields on theeligibility and benefits inquiry page: If you don’t have the member ID number, you maysearch using the patient’s last name, first name anddate of birth. Use the “Benefit Type” drop-down box to narrowdown to a specific benefit (for example, code 30 isfor general benefits, code 47 is for hospital benefits andcode 98 is for professional physicians andother services).On Availity.com, in the Aetna Payer Space, select the“Applications” tab to access your Managed Choice plan,Elect Choice plan and health maintenance organization(HMO) capitation member rosters.Patient Cost Estimator toolThe payment estimator lets you request an estimate ofyour patient’s financial responsibility on or before a dateof service. Fee Schedule (most directly contracted physicians[MD/DO] can access their negotiated rates for CurrentProcedural Terminology [CPT ] and HCPCS codes) Claims and payment policy tools- Code Editing tool and Clinical & Payment PolicyLookup — to determine how procedure codes billedby themselves or in combination with other procedurecodes may be processed and to determine eligibilityof an assistant surgery procedure- Policy Information — to find policy-related links ifyou’re searching for general information on a topic orif you don’t have a specific procedure codeClaims Explanation of Benefits (EOB)on Remittance Viewer toolThis tool allows providers and office staff to accessclaims EOB statements online within 24 hours ofclaims processing. You may also use this tool forclaims reconsiderations.You can also: Get reliable estimates of the patient’s copayments,coinsurance and deductibles Access printable information to help you initiatefinancial discussions with your patients beforeor at the time of careThis tool can reduce, and possibly eliminate,after-the-fact financial surprises for you andyour patients.*Your administrator must enable this feature for you.6

Account management toolsAuthorizationFor other reporting capabilities and for submittingclaims reconsiderations, you can use the suite ofaccount management tools:Use our online tools to help you determine if authorization(also called “precertification”) is required for a particularprocedure, and submit precertification requests for thoseservices. Claim History Report (which allows you to identifyspecific codes) Single or multiple claims reconsiderationsReferralsIf a plan requires a referral, the PCP should issue it forall specialist visits, including visits in a hospital clinic. Referrals may be issued for consultation and treatmentby using the CPT code 99499. Referrals are valid for 1 year, and the first visit mustbe used within 90 days. Precertification Code Search tool — allows you toenter up to five CPT codes at a time to quicklydetermine whether a medical precertification isrequired for your patient. Online precertification transaction — allows you toadd a precertification request for those servicesthat require it and see if a precertification hasbeen authorized. All precertification requests should be done viathe online precertification transaction. A diagnosis code isn’t required; however, it’s veryhelpful for the specialist.Electronic funds transfer (EFT)email notification Direct access: Referrals aren’t required for routine eyecare and ob/gyn services. Refer to the Health CareProfessional Toolkit for other direct-access specialtiesin your area.For those already enrolled in EFT, you may now signup to enroll up to two email addresses. We’ll then notifyyou when we transmit to your bank. A referral isn’t a substitute for authorization of a servicethat requires precertification.Electronic remittance advice (ERA) Referrals may be issued to an individual specialist usingtheir national provider identifier (NPI) or to a specialtyusing the taxonomy code. Our online “Provider search” can be used to find aparticipating provider. Referrals can be issued for automatic studies byspecialty — services performed in a specialist officewhen patients are seen for visits and evaluations. Thishappens as a result of our direct-access programs orwhen a service is authorized by a referral from their PCP.Sign up to receive ERA through our provider websiteor your vendor or clearinghouse. Providers billing withmultiple NPIs will get separate payments for each NPI,unless you notify us otherwise. You can get claimsgrouped into payments based on TIN and billing address.Update Aetna provider demographicsSubmit updates and changes to your profile, includingaddress; hospital affiliations; the NPI for you, yourpractice or facility; and demographics.7

Claims how-toElectronic claims submissionClaims addressesSubmit all claims electronically for your patients,regardless of their benefits plans.If your practice management or hospital informationsystem requires a claims address for submission ofelectronic claims, or if your office doesn’t have electroniccapabilities, please refer to the table below for the claimsaddress for your state. Or refer to this list of payer IDs. If you’re already using a vendor, add us to your listof payers. To view a list of our participating claims vendors,visit our vendor page. Send professional claims free of charge from ourprovider website. You can also send voided or corrected professionalclaims from our provider website.We typically don’t need attachments. If we do, we’ll letyou know what we need and how to send it to us.Claims submission tipsTo ensure accurate and timely claims payment, besure to: Review rejection reports from your vendor Correct and resubmit rejected claims electronicallythrough your vendor Ensure that the member and patient names and IDnumbers are correct Ensure that CPT and diagnosis codes are validDisagree with a claims decision?Write to the PO box listed on the EOB statement or thedenial letter related to the issue being disputed. Pleaseinclude the reason(s) for the disagreement.Medical providerlocation by stateClaims mailingaddressAL, AK, AR, AZ, CA,FL, GA, HI, ID, LA, MS,NC, NM, NV, OR, SC,TN, UT and WAAetnaPO Box 14079Lexington, KY40512-4079CO, CT, DC, DE, IA, IL,IN, KS, KY, MA, MD, ME,MI, MN, MO, MT, ND,NE, NH, NJ, NY, OH, OK,PA, RI, SD, TX, VA, VT,WI, WV and WYAetnaPO Box 981106El Paso, TX79998-1106For all Medicare and Aetna Student HealthSM plans,use the El Paso, TX, claims mailing address.For all Aetna Voluntary plans and limited benefitsinsurance plans (formerly “Aetna AffordableHealthChoicesSM plans”), use the Lexington, KY, claimsmailing address.For Aetna Signature Administrators Preferred ProviderOrganization (PPO) plans, Aetna Workers’ CompAccess plans, Meritain HealthSM and Schaller Anderson(Medicaid), refer to the member ID card.Go to Aetna.com for more information.Select “Providers.” Under “Working with us,” choose“Dispute & appeal process.” Then, select “Learn aboutthe dispute process.”8