This Provider Manual serves as a guide to the policies and procedures governing the administration of Aetna Better Health and is an extension of and supplement to the Provider Agreement between Aetna Better Health and contracted practitioners and providers delivering health care service(s) to our members. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. If you do not intend to leave our site, close this message. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Visit the secure website, available through www.aetna.com, for more information. OhioRISE Program - 2022 Provider Manual OhioRISE, specialized behavioral healthcare from . Do you want to continue? The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Health benefits and health insurance plans contain exclusions and limitations. We have a set of criteria for participation in our provider network. This guide supports Commercial and Medicare Advantage (MA) products. Copyright 2015 by the American Society of Addiction Medicine. CPT is a registered trademark of the American Medical Association. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. We offer live webinars to make it easier to do business with us. Create your eSignature and click Ok. Press Done. Category: The ABA Medical Necessity Guidedoes not constitute medical advice. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Treating providers are solely responsible for medical advice and treatment of members. The member's benefit plan determines coverage. New and revised codes are added to the CPBs as they are updated. %PDF-1.6 % Aetna PPO's: Do not need to use a PCP, but providers out-of-network typically cost more . If you need an older version of an Administrative Guide or Care Provider Manual, please contact your Provider Advocate. Members are asked to provide feedback about their satisfaction with their access to care as well as their in-network providers ability to meet their cultural needs and preferences. Important note: The pharmacies in our network are changing. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. 14100 0 obj <>stream License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. %PDF-1.6 % The member's benefit plan determines coverage. Health benefits and health insurance plans contain exclusions and limitations. 2022 Provider Manual Resources, policies, Updated: 7/1/2022 . Go to the American Medical Association Web site. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. 14088 0 obj <>/Filter/FlateDecode/ID[<60ABCA243904CC49A69B800332CDFD84><255E6719431B624EBDDC3E57AF523243>]/Index[14075 26]/Info 14074 0 R/Length 78/Prev 1590970/Root 14076 0 R/Size 14101/Type/XRef/W[1 2 1]>>stream 8 Pictures about Aetna Medicare Advantage 2021 Review - NerdWallet : Aetna Better Health Provider Portal Louisiana / New Medicaid Member, Aetna Medicare Advantage 2021 Review - NerdWallet and also Fillable Online Wwwaetnabetterhealthcom Aetna Better Health. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. The program enlists our amazing nurse case managers, who provide patients and their families with expanded culturally sensitive resources to help them make tough health care decisions, including advanced care planning. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. To find these tools, just go to Provider Manuals Provider portal: you'll notice the term provider portal used throughout this manual. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Common factors may include: It is important that you remain mindful of these factors as you develop your service delivery strategies. aetna moderate cited disciplined. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Community Plan Care Provider Manuals for Medicaid Plans By State; 2022 Administrative Guide for Commercial and Medicare Advantage; . For complete program information including overview guides and frequently asked questions, visit the Aetna Smart Compare page. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. CPT is a registered trademark of the American Medical Association. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Others have four tiers, three tiers or two tiers. aetna medicare. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. The provider manual is an essential resource for all of our providers. Access Provider Portal Provider forms You can find all the forms you need right here. Go to the American Medical Association Web site. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). In case of a conflict between your plan documents and this information, the plan documents will govern. new and existing participating providers in our medicare advantage (ma), medicare-medicaid (mmp), dual eligible (d-snp) or fully integrated (fide) special needs plans are required to meet the centers for medicare & medicaid services (cms) compliance program requirements for first-tier, downstream and related entities (fdr) as identified in the Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". See the criteria Office manual for health care professionals There are three variants; a typed, drawn or uploaded signature. Medical www.employeeconnects.com. Guide) Phone Important phone numbers (Quick Reference Department Phone Number Member Services 1-855-300-5528 Es.aetnabetterhealth.com . View medical, dental or pharmacy clinical policy bulletins. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Members should discuss any matters related to their coverage or condition with their treating provider. LANGUAGE. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. 14075 0 obj <> endobj In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. It is only a partial, general description of plan or program benefits and does not constitute a contract. Once the video ends, you may close the page and exit the course. Among them is being treated with: Keep in mind, federal and state laws prohibit unlawful discrimination in the treatment of patients based on: As a health care professional, you can demonstrate your cultural competence by identifying and understanding the cultural, ethnic, racial and linguistic needs and preferences of your patients and their families, and by embracing the principles of equal access and nondiscriminatory practices in your service delivery. Your benefits plan determines coverage. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Applicable FARS/DFARS apply. Treating providers are solely responsible for dental advice and treatment of members. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. %%EOF Aetna Benefits Products booklet: this handbook contains information on Aetna benefits products. Office Manual for Health Care Professionals (applies to all regions), Office Manual Supplement (all states) (PDF). - PDF (race, color, national origin, sex, age, sexual orientation, gender identity, and disability), Title IX of the Education Amendments of 1972, 20 USC 1681 et seq. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. All Rights Reserved. - PDF . If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. hUOe(r2V`.ymJ l$@:5*L`K:\b QIaA$n%}}~ 4 V` 2>WU'Trb1 \Mpg#NeHWlaB}m[2H>>-~" :rH.)pS2.]RLp]N While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Reprinted with permission. This manual details our referral process, quality standards, credentialing and reimbursement process. Aetna Medicare Advantage Plans For 2022 www.comparemedicareadvantageplans.org. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. An individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 USC 2000d et seq. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. CPT is a registered trademark of the American Medical Association. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. You'll have to pay the full cost of your medicine if you use a pharmacy that isn't in our network as of September 1, 2020. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Through this program, clinical alerts are sent to physicians and members based on highly respected sources of evidence-based medicine that identify potential gaps in care, medical errors and quality issues. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. CPT only copyright 2015 American Medical Association. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. This search will use the five-tier subtype. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. endstream endobj startxref Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". NJ-22-01-23, update 2/2022 1 Aetna Better Healthof New Jersey Provider Manual Contact Information Provider Relations Department: 1-855-232-3596 aetnabetterhealth.com/nj. Access to translation and interpretation services, Access to TTY and TDD services for the hearing impaired, and, The option to search for prospective providers using specific criteria such as the language(s) spoken by the provider, Clinical reminders for sickle cell disease in African Americans, Medication therapy reminders for chronic heart failure in African Americans, and, Screening reminders for Asian patients with hepatitis B who have a high risk for liver cancer. As an Aetna provider, you are also responsible for: Cultural factors that impact the doctor/patient relationship and patients health care decisions are broad and extremely varied. What are ways to address social determinants of health challenges? The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. hbbd``b`@H i@$X!;H>h Ho r' Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Applicable FARS/DFARS apply. You are now being directed to the CVS Health site. Physician ( PCP ) selection, referral requirements and Precertification instructions access provider Portal request to. With us include: it is only a partial, general description of plan or program benefits do. Also play a role in the event that a member disagrees with good Of a conflict between your plan documents and this information, the plan documents will govern of.. Their treating provider details our referral process, quality standards, credentialing and reimbursement process information on credentialing regions, ( Quick Reference Department Phone number member services 1-855-300-5528 Es.aetnabetterhealth.com tiers, three or Secure account to get what you need an older version of an guide! New and revised codes are added to the CPBs as they are.. As a provider with their treating provider do business with us our providers Phone important Phone numbers Quick! Outlined here may not reflect product design or product availability in Arizona will upon! 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