Aetna. CCHCA Physician Handbook (7 th Edition)

Transcription

1 Part II Section A Aetna Introduction 1 Verifying Aetna Member Eligibility and Benefits 1 Aetna Sample Member ID Card 2 Aetna Prescription Drug Program 3 Pharmacy Benefit 4 Prior Authorization for Medications 4 Aetna Specialty Pharmacy 4 Medication Prior Authorization Forms 5 Specialty Medication Request Form 7 CCHCA Physician Handbook (7 th Edition)

2 Aetna Introduction CCHCA is a participating medical group under Aetna. Aetna is one of the nation s leading diversified health care benefits companies, serving members with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life, long-term care and disability plans and medical management capabilities. The addition of Aetna to the existing CCHCA programs will further enhance the access of bilingual providers and quality health care in a culturally sensitive setting to our community. Authorizations, claims, and utilization for Aetna members who are enrolled under the CCHCA Medical Group/Chinese Hospital will be handled in the same manner as the other CCHCA programs. Please refer to the CCHCA guidelines in this manual for further information or reference. CCHCA utilizes Primary Care Physicians (PCP) for the Aetna Program. The same utilization protocol is used as in our other CCHCA programs. Members who have chosen CCHCA as their medical group must use CCHCA plan physicians for services. Referral physicians must also be from within the medical group. Exceptions require prior authorization from the Utilization Management Department. All claims, and authorizations for Aetna members enrolled under the CCHCA medical group will be processed by the Health Plans Office. Refer to Part I, Section 7 for the mailing address for paper and electronic claims. (Do not submit claims to Aetna. This will only cause delay in payment of your claims, as the claims will be returned to our office for processing. ) The Aetna program also utilizes a co-payment system. The amount to be collected varies for each plan, and should be collected from the patient at the time of service. Some of the member ID cards will carry the amount of the office visit co-payment. Verifying Aetna Member Eligibility and Benefits Eligibility and benefits can be obtained through the Aetna website at If you have any questions concerning patient eligibility, benefits or co-payments, please call Aetna directly at CCHCA Physician Handbook, Part II, Section A - 1 -

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4 Aetna Prescription Drug Program Pharmacy Benefits The pharmacy benefit for Aetna members is administered by Aetna. Members or providers should call Aetna Pharmacy Management Customer Service at (800) for further information regarding the pharmacy coverage. Prior Authorization for Medications Certain drugs may require prior-authorization before the drug is covered. Authorization for medications requiring prior authorization can be obtained by calling (800) (A sample copy of the prior authorization medication request form can be found on the ensuing pages). Aetna Specialty Pharmacy Aetna has a Specialty Pharmacy program that provides specialty oral medications, self-injectables, and medications administered at the doctor's office. These medications often require special storage and handling and may not be readily available at the local drugstore. Aetna Specialty Pharmacy also works closely with physicians and provides education and clinical support to better assist patients. This helps to streamline the care delivery process and maximize the success of the patient s treatment. If you have any questions concerning specialty drugs, please call (A sample copy of the Specialty Medication Request Form can be found on the ensuing pages). CCHCA Physician Handbook, Part II, Section A - 3 -

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