This guide supports Commercial and Medicare Advantage (MA) products. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. To further demonstrate our commitment to supporting our members cultural, ethnic, racial and linguistic needs, we also provide members with: We also provide our internal health care professional staff with ongoing cultural competency training to deepen their understanding of the social determinants of health and other disparities among racial and ethnic groups. Get the provider manual (PDF) Provider Portal Request access to check member eligibility and benefits. NJ-22-01-23, update 2/2022 8 Aetna Medicaid distinguishes itself by: years' experienceMore than 30 managingthecareand costsof the TemporaryAssistancefor NeedyFamilies(TANF), hildren's Health Insurance Program ( HIP) and Aged, lind and Disabled (ABD . 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 Please be sure to add a 1 before your mobile number, ex: 19876543210, Precertification lists and CPT code search. See the criteria Office manual for health care professionals LANGUAGE. Do you want to continue? While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. If you do not intend to leave our site, close this message. Print Email. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. You are now being directed to the CVS Health site. Applicable FARS/DFARS apply. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. This guide explains how to work with us. Visit the secure website, available through www.aetna.com, for more information. The member's benefit plan determines coverage. Create your eSignature and click Ok. Press Done. Links to various non-Aetna sites are provided for your convenience only. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Aetna BetterHealth is not responsible or liable for non-Aetna Better Health content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. 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. For complete program information including overview guides and frequently asked questions, visit the Aetna Smart Compare page. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. 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. 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. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Others have four tiers, three tiers or two tiers. 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. Treating providers are solely responsible for medical advice and treatment of members. Aetna's 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). The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. This information is neither an offer of coverage nor medical advice. The Aetna Smart Compare designation helps give our members more information to help them choose a practice for themselves and their families. To find these tools, just go to Provider Manuals Provider portal: you'll notice the term provider portal used throughout this manual. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. medical. Once the video ends, you may close the page and exit the course. Each main plan type has more than one subtype. 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). 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. 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. The ABA Medical Necessity Guidedoes not constitute medical advice. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. We have a set of criteria for participation in our provider network. Aetna provider identification number (PIN)16 Accessibility standards and participation criteria16 Primary care provider (PCP) responsibilities 16 Use your search tool to see if precertification is required. 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. Your benefits plan determines coverage. Each main plan type has more than one subtype. Communication among health care professionals can lead to better outcomes for patients, and you might have questions about how to discuss sensitive topics. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. f9(HEw6,Y!=#qySuf{Z~1u~rCN1j#53s^:nsByLRa_(LEkf]^$T.67:nlL{DsjkvB7/ [:cFB3^`8#fw^ZY[{ 3\0)[ . Office Manual for Health Care Professionals, Womens Health Programs and Policies Manual, Explain members rights in the health care environment, Explain your responsibility in providing culturally competent care, Explain Aetnas commitment to cultural competence, and, Identify current Aetna programs that promote cultural competence as well as racial and ethnic equality, Socio-economic status - just to name a few, Recognizing your personal views about others and how they impact your professional interactions, Respecting the cultural, ethnic, racial and linguistic needs of your patients and, Incorporating your patients language, race, ethnic and cultural preferences in your service delivery strategies. Members should discuss any matters related to their coverage or condition with their treating provider. Category: If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. In addition, we also fax an annual Physician Satisfaction Survey to ensure we are adequately providing you with tools and resources to meet your patients cultural needs. - 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. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Some subtypes have five tiers of coverage. 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 guide is a reference tool to help contracting delegates and their staff understand how to perform delegated functions to Aetna standards. 14100 0 obj <>stream No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. hbbd``b`@H i@$X!;H>h Ho r' Provider manuals about our policies and programs You can view and download these manuals: Office Manual for Health Care Professionals Behavioral Health Provider Manual EAP Manual Women's Health Programs and Policies Manual 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. Copyright 2015 by the American Society of Addiction Medicine. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Aetna Premier Care Network/Aetna Premier Care Network Plus Provider Guide (PDF). 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. Go to the American Medical Association Web site. Applicable FARS/DFARS apply. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. As part of our commitment to creating a health care environment that supports our members cultural, ethnic, racial and linguistic needs, Aetna has created several programs to align this organizational strategy. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Community Plan Care Provider Manuals for Medicaid Plans By State; 2022 Administrative Guide for Commercial and Medicare Advantage; . 3 2022 Provider Manual - Aetna. Follow the step-by-step instructions below to eSign your aetna appEval form: Select the document you want to sign and click Upload. The member's benefit plan determines coverage. One element of this program focuses on African-American women, and results have shown that moms enrolled in the program were more likely to have full-term babies than moms not enrolled in the program. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Treating providers are solely responsible for dental advice and treatment of members. For language services, please call the number on your member ID card and request an operator. 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). Reprinted with permission. To demonstrate our commitment to meeting these standards and to monitor, track, and improve upon our members experiences, we conduct an annual member outreach campaign using the Consumer Assessment of Healthcare Providers & Systems. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. The provider manual gives you easy access to information about a wide variety of topics, ranging from how to file a claim, which services are covered for Aetna Better Health members, grievance and appeals processes and more. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. View medical, dental or pharmacy clinical policy bulletins. 1 - Services - - manual provider. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. CPT only Copyright 2020 American Medical Association. Good health and a good doctor/patient relationship begins with understanding your patients' cultural, ethnic, racial and linguistic needs. Treating providers are solely responsible for medical advice and treatment of members. CPT only copyright 2015 American Medical Association. 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. Watch this presentation to learn more about cultural competence and the important role you play as a provider. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. 14075 0 obj <> endobj 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. Aetna PPO's: Do not need to use a PCP, but providers out-of-network typically cost more . Health benefits and health insurance plans contain exclusions and limitations. 1126773-01-01 (9/22) . Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. All Rights Reserved. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 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. If you do not intend to leave our site, close this message. Aetna Medicare Advantage Plans For 2022 www.comparemedicareadvantageplans.org. - PDF . hUOe(r2V`.ymJ l$@:5*L`K:\b QIaA$n%}}~ 4 V` 2>WU'Trb1 \Mpg#NeHWlaB}m[2H>>-~" :rH.)pS2.]RLp]N CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. 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. Using providers that are in the plan's network may cost less. 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. f9(HEw6,Y!=#qySuf{Z~1u~rCN1j#53s^:nsByLRa_(LEkf]^$T.67:nlL{DsjkvB7/ [:cFB3^`8#fw^ZY[{ 3\0)[ . Treating providers are solely responsible for medical advice and treatment of members. Aetna's 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). Please log in to your secure account to get what you need. Aetna Dental www.aetnafeds.com 1-800-554-2042 . 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. Applicable FARS/DFARS apply. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. SECTION VII: PROVIDER SERVICES AND RESPONSIBILITIES . Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. The provider manual is an essential resource for all of our providers. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Provider manuals You will find guides to support you in providing care, managing your practice and working with us. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 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