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Support systemBehavioral Health Provider ManualAetna.com23.20.800.1 P (4/21)
Table of contentsIntroduction .3Our programs.4Clinical delivery .7Quality programs . 14Working electronically with us.22Appendix A: Aetna Behavioral Health treatment record review criteria and best practices . 24This Behavioral Health Provider Manual, the EAP Manual and other related communications are posted on Aetna.com,on the Provider Education & Manuals page.Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies(Aetna). Aetna Behavioral Health refers to an internal business unit of Aetna.2
IntroductionWelcome to the Aetna Behavioral Health networkOur behavioral health programs focus on the important role of mental health on a person’s overall well-being.We’ll give you valuable tools to help you work with us and provide quality service to our members. This manualis an extension of your contract with us. All practitioners and facilities must abide by the conditions set forth inyour contract and in our provider manuals.Our guiding principlesHow to reach usOur behavioral health programs support our beliefin the following:Our medical directors and staff are available to speakwith you about utilization management issues. They’reavailable, during and after business hours, via toll-freetelephone numbers. Behavioral health medical directorsmake all final coverage* denial determinations involvingclinical issues. Enhancing our members’ — your patients’ —clinical experiences Adhering to the importance of the mind-bodyprinciple and connection Providing a treatment approach that isevidence-based, goal-directed, and consistent withaccepted standards of care, all Aetna Clinical PolicyBulletins, and Aetna clinical practice guidelines Providing treatment that is medically necessary Educating members about the risks and benefits ofavailable treatment options Developing a strong relationship with you,informing you about resources, and concentratingon continuity of care among all, for the benefit ofyou and your patients Integrating behavioral health care across ourproduct spectrumWhat you’ll find in this manualWe developed this manual with you in mind — giving youwhat you need to work with us and make administrationeasier. This manual contains information about: Network participationCondition management ite visits and monitoringContact information/how to reach usClinical practice guidelinesAuthorization and referral processesMember and provider denials and appealsCase managementQuality programsWorking with us electronically, and much moreIf a treating provider doesn’t agree with a decision aboutcoverage or wants to discuss an individual member’scase, Aetna Behavioral Health staff are available 24 hoursa day, 7 days a week. Behavioral health care providerscan contact staff during normal business hours(8 AM to 5 PM, Monday through Friday)** by calling thetoll-free precertification number on the member’s IDcard. When only a Member Services number is shownon the card, you’ll be directed to the Precertification unitthrough either a phone prompt or a Member Servicesrepresentative.On weekends, company holidays, and after normalbusiness hours, members and providers can use thesesame toll-free phone numbers to contact our staff.Our staff identify themselves by name, title andorganization when they initiate or return calls aboututilization management issues. We also offer TDD/TTYservices for deaf, hard-of-hearing, or speech-impairedmembers, and language assistance for members todiscuss these issues.*For these purposes, “coverage” means either the determination of (i) whether or not the particular service ortreatment is a covered benefit under the terms of the particular member’s benefits plan, or (ii) where a physician orhealth care professional is required to comply with the Aetna patient management programs, whether or not theparticular service or treatment is payable under the terms of the provider agreement.**All continental U.S. time zones; hours of operation may differ based on state regulations. In Texas: 6 AM to 6 PM CT(Monday through Friday) and 9 AM to noon CT on weekends and legal holidays. Phone recording systems are in useduring all other times.3
Our programsBehavioral Health ConditionManagement programWe offer a case management program that supportspatients’ medical and psychological needs. Our focus ison helping our members make the best use of theirbenefits by coordinating behavioral health and wellnessservices. To support the efforts of clinicians, we alsoclosely follow patient progress and treatmentrecommendation adherence and share it with you.Through this program, we: Work with your practice and other health careprofessionals on patient progress Evaluate patient needs to promote full use ofcovered services and benefits in support of yourtreatment plan Provide educational materials and decision-supporttools, both online and via mail, so patients betterunderstand their illness Use case management by phone to support patientadherence to your treatment planThis program provides additional care options for youreligible Aetna patients.Who may benefit from our Behavioral HealthMember Support program Aetna members (children, adolescents and adults):- With co-occurring medical and behavioralhealth conditions- With complex behavioral health conditions whohave had inpatient readmissions, extendedhospitalization stays, or suicide attempts resultingin medical admissions Aetna members ages 14 and older:- Who have symptoms of major depression,dysthymia, depression not otherwise specified, orbipolar depression- Who are diagnosed with anxiety disorders, such asgeneralized anxiety, panic disorder, or post-traumaticstress syndrome Aetna members ages 18 and older who have an alcoholproblem, including alcohol dependence or a moresevere alcohol use disorder4Members who complete this program show significantsymptom relief and improvement in overall health.To learn more about the Aetna Behavioral HealthMember Support program, call us at1-800-424-4660 (TTY: 711).We’ve developed a spectrum of behavioral healthservices for our members. In doing so, we contract withlicensed psychiatrists, psychologists, social workers andother master’s-prepared clinicians. Among thesepractitioners, numerous clinical, linguistic, and culturalspecialties are represented to serve individual memberand geographic needs. Our goal is to create acollaborative relationship with the behavioral healthcare professional community. We believe that the keyto quality care and member satisfaction is a diverse,well-informed, quality network. To accomplish this, wecredential clinicians who are independently licensed andwell trained in their particular area of expertise.Credentialing and recredentialingA behavioral health care professional must becredentialed by us before joining the behavioralhealth network.We use a standard application and a common databasethrough the Council for Affordable Quality Healthcare(CAQH ) to gather credentialing information.Our recredentialing processWe reassess a provider’s qualifications, practice andperformance history every three years, depending onstate and federal regulations and accrediting agencystandards. This process is seamless to providers who aredue for recredentialing and whose applications arecomplete within the CAQH database.We’ll send providers (whose applications aren’t completewithin the CAQH database) three reminder letters. Theletters will ask them to update their recredentialing data.If they don’t respond to the letters, we’ll call them.How can I check the status of myrecredentialing application?Call our Credentialing Customer Service departmentat 1-800-353-1232 (TTY: 711).Just go to the “Request participation“ section of ourwebsite to start the application process.
The minimum criteria to become a credentialed Aetnabehavioral health care professional are: Graduation from an accredited professional schoolapplicable to the applicant’s degree, disciplineand licensure For physicians, completion of residency training inpsychiatry and board certification, unless thephysician meets the conditions delineated in ourboard certification exception policy; a medicaldirector reviews exceptions to the boardcertification requirement Malpractice insurance in amounts specified in theAetna agreement Availability for emergencies by mobile device or otherestablished procedures that we deem acceptable Submission of an application containing all applicableattestations, necessary documentation and signatures If applicant is a physician addictionologist, certificationby the American Society of Addiction Medicine (ASAM) Current, unrestricted license The absence of current debarment or suspension fromstate or federal programsSite visits and monitoringWe make office site visits to network practitioners aftergetting a member’s complaint. We evaluate the physicalaccessibility, physical appearance, and adequacy ofwaiting and exam room space related to the settingsin which member care is given.We set standards for office site criteria and medicalrecord-keeping practices. If a site visit is required formember complaints to evaluate the physical accessibility,physical appearance, or adequacy of waiting and examroom space, we also review the medical record-keepingpractices. We assess methods used for keepingconfidentiality of member information. We also assessmethods for keeping information in a consistent,organized manner for ready accessibility.No site visit is required for complaints about availability ormedical record keeping. The office assessment criteriaare stated in the practitioner agreements and businesscriteria of the practitioner agreements. The medicalrecord-keeping practice standards are stated in themedical record criteria that we distribute to practitioners.Also see Appendix A on page 24 for more information.Open the door to electronic communicationsOur electronic correspondence option allows your officeto get information from us online instead of on paper.Read the Aetna Behavioral Health Insights providernewsletter and other time-sensitive correspondenceonline. We’ll send you an email when the newsletteror other communications are ready to view.5
Notification of status changesBehavioral health care professionals are required tonotify us in writing within 14 days of any changesrelated to the following circumstances: Change in professional liability insurance Change of practice location, billing location,telephone number or fax number Status change of professional licensure, such assuspension, restriction, revocation, probation,termination, reprimand, inactive status or anyother adverse situation Change in tax ID number used for claims filing Malpractice event, as described in the “Compliancewith Policies” section of the health care professionalcontract (provider or specialist agreement)Note:Providers who previously practiced only undera group and are now starting a solo practicerequire an individual contract.Questions? General: call our Provider Service Center, which isavailable from 8 AM to 5 PM. Health maintenance organization (HMO)-based andAetna Medicare Advantage plans: call1-800-624-0756 (TTY: 711). All other plans: call 1-888-MDAetna (TTY: 711) or1-888-632-3862 (TTY: 711), or visit Availity.com, ourprovider portal.Update your office’s contactinformation onlineIf you need to change or update your office’s contactinformation (new email, mailing address, phone/fax numbers),go to Availity.com and access our provider portal.Having your correct email address on file is veryimportant to us. It’s our preferred and efficient wayof communicating important information to you.Please fax correspondence about changes to859-455-8650.Behavioral health care provider access-to-care standards*ServiceTime frameNon-life-threateningemergency needsWithin 6 hours of requestUrgent needsWithin 48 hours of requestRoutine office visits Initial visit within 10 business days of request Follow-up visits should be available within 5 weeks for behavioralhealth practitioners who prescribe medications, and within 3 weeksfor behavioral health practitioners who don’t prescribe medications.Following hospital discharge for abehavioral health conditionWithin 7 days of the inpatient discharge dateAfter-hours careEach behavioral health practitioner must have a reliable 24 hours a day,7 days a week live answering service or voicemail message. MDs must have a notification system or designatedpractitioner backup. Non-MDs, at a minimum, must have a message systemthat gives contact information to a licensed professional.*More stringent state requirements supersede these accessibility standards.6
Online security is more important than ever in today’shigh-tech world. Our provider portal lets you validate theinformation you submit. It also ensures that unauthorizedindividuals aren’t submitting incorrect information aboutyour office or facility. Your security officer can makechanges to your information, or they may give accessto others.You’ll need to register for our provider portalTo use the provider portal, you must first register.And it’s easy! Then, you’ll also be able to submit claimstransactions, check member eligibility and benefits,and verify referrals.Clinical deliveryAccess to careMembers may access behavioral health care inthree ways:1. Through direct access to the behavioralhealth provider2. Through a recommendation from the primary carephysician or other treatment provider3. Through a referral from an employee assistance orstudent assistance program providerFor a list of services that require precertification andconcurrent review, go to AetnaElectronicPrecert.comand click “Check our precertification lists.” To requestprecertification, use our provider portal at Availity.com orany other website that allows you to send precertificationrequests electronically. (You can register at Availity.comfor our provider portal via Availity .) You may also use thetoll-free behavioral health telephone number on themember’s ID card. For Open Choice and TraditionalChoice plan members, use the toll-free MemberServices telephone number on the member’s ID card.These numbers are accessible 24 hours a day, 7 days aweek. A screening process to determine the urgency ofthe need for treatment may occur at the time of the call.Authorization and precertification processAuthorization/precertification is the process ofdetermining the eligibility for coverage of the proposedlevel of care and place of service.* To ensure Aetnamembers receive the highest quality of care, acomprehensive diagnostic evaluation prior to theinitiation of treatment is expected. Diagnoses submittedon claims must be current and consistent with the mostrecent Diagnostic and Statistical Manual of MentalDisorders (DSM) criteria. Collecting complete andaccurate clinical data is critical to successfullycompleting the authorization process. Treatmentapproach is expected to be evidence based, goaldirected, and consistent with accepted standards ofcare, Aetna Clinical Policy Bulletins and Aetna clinicalpractice guidelines.It is also expected that treatment provided is medicallynecessary: “Medically necessary services are thosehealth care services that a practitioner, exercisingprudent clinical judgment, would provide to a patient forthe purpose of preventing, evaluating, diagnosing ortreating an illness, injury, disease or its symptoms, andthat are (a) in accordance with generally acceptedstandards of medical practice; (b) clinically appropriate,in terms of type, frequency, extent, site and duration, andconsidered effective for the patient’s illness, injury ordisease; (c) not primarily for the convenience of thepatient, physician or other health care provider; and (d)not more costly than an alternative service or sequenceof services at least as likely to produce equivalenttherapeutic or diagnostic results as to the diagnosis ortreatment of that patient’s illness, injury or disease. Forthese purposes, ‘generally accepted standards of care’means standards that are based on credible scientificevidence published in peer-reviewed medical literaturegenerally recognized by the relevant medical community,or otherwise consistent with physician specialty societyrecommendations and the views of physicians practicingin relevant clinical areas and any other relevant factors.”Some employers have specific preauthorizationrequirements for their employees, so always checkwith our Provider Service Center at 1-800-624-0756(TTY: 711) for HMO and Medicare Advantage plans and1-888-MDAetna (1-888-632-3862) (TTY: 711) forall other plans. All inpatient behavioral health services must beprecertified and are managed through a concurrent orretrospective review process. Intermediate levels of care, such as residentialtreatment, and partial hospitalization also requireprecertification. For more information, go toAetnaElectronicPrecert.com and click “Check ourprecertification lists.”*Precertification is the process of collecting information before inpatient admissions and selected ambulatory proceduresand services for the purpose of (1) receiving notification of a planned service or supply, or (2) making a coveragedetermination. It doesn’t mean precertification as defined by Texas law as a reliable representation of payment.7
Exceptions:This policy applies to all Aetna plans with the exceptionof behavioral health benefits that we administer butdon’t manage and self-funded plans with plansponsors that have expressly purchasedprecertification requirements. In addition to reviewing clinical information todetermine coverage, our utilization managementclinician will discuss treatment alternatives, theappropriate level of care and explore dischargeplanning opportunities. If Aetna case management isinvolved, we will request that the member’s family,physician(s), and other health care professionals beinvolved in the treatment plan and activities. Werecommend that you discuss the available benefits foroutpatient care with your patient, so that treatment canbe planned accordingly.You can submit a precertification request in one ofthree ways:1. Through Availity.com (our provider portal)2. Through one of our vendors — go toAetna.com/provider/vendor to see our list3. By calling our Provider Service Center at1-800-624-0756 (TTY: 711)Learn more.Note:Stepping down to a less restrictive level of care within thesame facility (for example, a step down from inpatientdetoxification to inpatient rehabilitation), even within thesame unit of the same facility, requires precertification.At times, a member may seek treatment outside of ournetwork (for example, a nonparticipating referral forroutine outpatient behavioral health services). This is awritten or verbal request that we review. Reasons that anonparticipating referral may be approved include: When a specific health care professional preferredby the member isn’t available in network (and themember’s plan provides coverage forout-of-network services) When the member is continuing, or returning to,treatment with a nonparticipating health careprofessional, i
Behavioral Health Condition Management program We offer a case management program that supports patients’ medical and psychological needs. Our focus is on helping our members make the best use of their benefits by coordinating behavioral
