RECONTRACTING 10/31/2016. Aetna Medicare Advantage. Aetna Behavioral Health

Transcription

1 DOING BUSINESS WITH AETNA & COFINIT Y 1 2 RECONTRACTING -Separate agreements. -Separate networks. - Aetna is a Payer, Cofinity is a Network Access Agreement. Aetna Medicare Advantage Employer Based Plan. - PPO Product. - Physician Services Based on Medicare Reimbursement. - Follows Aetna coding and guidelines. Aetna Behavioral Health -Separate agreements. -Separate networks. - Adding a new Behavioral Health Provider, visit / Health Care Providers / Join the Network / Select Behavioral Health Applications - Aetna Behavioral Health Customer Service:

2 MERITAIN HEALTH, AN AETNA COMPANY QUICK OVERVIEW A guide for doing business with Meritain Health Contracts Since Meritain Health is a fully owned Aetna subsidiary, if contract includes PPO or Choice POS II products, then your contract also applies to Meritain Health patients who have elected the Aetna network. Please note that Meritain is no longer a part of Aetna Signature Administrators. Sample ID card Recognizing a Meritain member To identify a patient who is using the Aetna network through Meritain, look for the Meritain logo and network by Aetna on the patient s member ID card. Meritain does work with other networks. If an employer selects a network other than Aetna for their employees, Meritain will follow the rules governing those network contracts. Aetna s responsibility Handle claims pricing Provide network access services and management Resolve provider contract issues Meritain s responsibility Handle claims processing Provide customer service Conduct utilization review to determine medical necessity based upon Aetna Clinical Policy Bulletins (criteria) If you don t have access to the website or ID card, call AETNA S HEALTH CARE PROFESSIONALS WEBSITE OPTIONS AVAILABLE WITHOUT LOGIN 5 PROVIDER DEMOGRAPHIC REQUESTS INCLUDE: New Provider Enrollments Is your new Provider already participating in the Aetna/Cofinity Network? Find out at: Aetna Provider Services Cofinity Customer Service If not, contact Aetna Credentialing at to determine the provider s Aetna credentialing status. Updates to Current Providers Do you have changes to your Practice address, Tax ID, or New Patient Status? Need to submit a Provider Termination from your Practice? 6 2

3 SUBMIT DEMOGRAPHIC CHANGES Aetna: Via below form at aetna.com (under Healthcare Professionals and then Helpful Links ) or via NaviNet by Security Officer Cofinity: Via website or send directly to ProviderRelations@Cofinity.net Please allow days for Aetna s and Cofinity s Provider Data Service Teams to process Provider maintenance requests. 7 NEW PROVIDER ENROLLMENTS Provider IS credentialed by Aetna to participate but is not currently tied to your Practice Tax ID. Aetna Direct Groups >NaviNet NaviNet Security Officer transaction or > Health Care Professionals Update Provider Demographic Data Submit or >Fax Letter to Provider Data Maintenance at Provider is NOT currently credentialed by Aetna to participate. Aetna performs credentialing for Aetna and Cofinity Network Participation. > Health Care Professionals Join the Network Submit or >Contact Aetna Credentialing by Phone at Cofinity Network Groups > Find by Customer Provider Contact Us or > Provider Add request to ProviderRelations@cofinity.net or >Contact Cofinity Customer Service by phone at You will need to select: Medical, Dental, or Behavioral If Medical then 2 options: Mid-level (Non-credentialed) or All Other (Credentialed) Provide all Demographic Details: including CAQH #, TIN (if joining a par tin must use group tin), , NPI, License #, if PCP/Spec and more 9 3

4 AETNA CREDENTIALING FAQs 1. I've heard of an organization called the Council for Affordable Quality Healthcare or CAQH. Can you tell me more about this organization? Answer: Yes, CAQH is a nonprofit alliance of America s leading health plans allowing providers to submit one application to meet the needs of all of the health plans and hospitals. 2. If I am already registered with CAQH, what are my next steps? Answer: Please ensure that you have granted Aetna authorization to review your information. 3. If I have not yet registered with CAQH, what are my next steps? Answer: If you have not completed CAQH s online registration, you will receive a registration kit from CAQH within 7-10 business days after submitting your online application. 4. How long does the credentialing process take? Answer: The credentialing process takes approximately 90-days post application submission date. You may check status of your application by contacting our Aetna Credentialing Department at # PROVIDER SERVICE CENTER: Aetna Medicare Service Center: Aetna Credentialing:

5 # # ENTER AETNA HEALTH PLAN Look for Access / Security Officer FAQs and Tips 15 5

6 # AETNA PLAN CENTRAL Left: Aetna Secure Options Center: Check Important Announcements Right: Links to Provider Resources 17 CONTACT AETNA PROVIDER SERVICES DIRECTLY ONLINE Example: Select Support Center / Doing Business With Us see many informational links At Bottom of most screens in Grey Box Under Tools Select Contact 18 6

7 19 20 CONTACT US FEATURE NaviNet Look for a gray shaded Contact link in the lower portion of the screen. Benefits of using the Contact feature include: Dedicated staff committed solely to managing requests directed to Aetna through the Contact feature. Estimated Turnaround Time for response varies by the complexity of your inquiry but you WILL get a response. Reconsideration option drives the claim back through the auto-adjudication process. Eliminates the need to contact the Aetna Service Center via phone. You will provide your own direct name, TIN or NPI, and phone for response. For member type inquires (options 1-5) will need to select Traditional plan (W ID# s) or HMO for Aetna Medicare, also will need Member ID number and Group number. Currently there is an inability to upload attachments with this feature, i.e. medical records, clinical notes, etc. Aetna is researching enhancements. 21 7

8 ELIGIBILITY 22 ELIGIBILITY DETAILS This box shows Product & COB Details Click here to view & Print ID Card 23 WHAT S NEW? ACCESSING ONLINE MEMBER ID CARDS Digital Member IDs Please remember - if an Aetna Patient shows you a digital or printed copy of their ID, you should accept it as valid proof of coverage. 24 8

9 PAYMENT ESTIMATOR / REQUEST SCREEN Type of estimate Billing provider Place of service Diagnosis code(s) Procedure code(s) Billed Charge Choose one 25 SEE ALLOWED FEES, PT. RESP., REDUCTIONS 26 REFERRALS 27 9

10 REFERRAL FORM 28 REFERRAL INQUIRY 29 PRECERTIFICATION 30 10

11 PRECERTIFICATION 31 PRECERTIFICATION FORM 32 PRECERTIFICATION 33 11

12 PRECERTIFICATION CODE SEARCH TOOL 34 ACCESS CLAIM PAYMENT & CODING POLICIES SELECT SUPPORT CENTER / CLAIMS 35 ACCESS WRITTEN PRICING POLICIES 36 12

13 ALPHABETICAL LIST 37 CLICK TO REVIEW AND PRINT 38 ACCESS EOB S RECOMMEND SEARCHING BY PATIENT 39 13

14 SUBMIT CLAIMS FOR RECONSIDERATION ONLINE GO TO CLIAM EOB TOOL / EOB SEARCH POPULATES CLAIM DATA ONLY RUNS BACK THROUGH SYSTEM (I.E. USE WHEN PROVIDER PAR STATUS UPDATED, OR LEVEL 1 APPEAL/RECON) GENERATES TRACKING NUMBER RESOLUTION GENERATES NEW EOB CANNOT SUBMIT NOTES APPROX. 2-3 WEEK TURNAROUND TIN Level Access 40 SUBMIT PROJECT REQUESTS (OVER 25 CLAIMS SAME ISSUE) Select Account Management Tools / Multiple Claim Reconsiderations Specialized Rep. to identify root cause and correct Can submit with just 2 examples, or list all claims Can also first request claim history report to get all claim IDs to copy 41 PROJECTS: APPROX. 45 DAY TURN AROUND WILL PROVIDE REPORT IF REQUESTED AND NEW FINANCIAL DETAILS 42 14

15 MEDICARE ATTESTATION Currently must be completed via NaviNet. If PHO / IPA NaviNet currently does not grant access (working on solution hopefully by end of year) For now this year only, these groups can send attest form with a roster / list of all Tax IDs. Send signed form and tin list to: MedicareFDR@aetna.com 43 WILL SHOW IF EXPIRED Check boxes for steps completed, fill in signature of person attesting and submit. 44 AETNA DISPUTE AND APPEALS PROCESS Mail Appeal letter and records or supporting documents to: Aetna Provider Resolution Team P.O. Box Lexington, KY Fax: Aetna Dispute/Appeals process is summarized on aetna.com First: Claim Reconsideration (or Level 1 appeal) o Submit within 180 days from initial claim decision. o Aetna has up to 60 days to review and respond. Next: Level II appeal must by filed within 60 days of the reconsideration or Level 1 response for HMO-based benefits plans for Indemnity and PPO-based benefits plans 45 15

16 RADIOLOGY PRE-AUTHORIZATION Med Solutions (DBA evicore Healthcare or MSI) is responsible for the preauthorization of high-tech outpatient diagnostic imaging procedures for Aetna members. Preauthorization is required for CT scans, Nuclear cardiology, MRI/MRA, PET scans, Sleep Studies and select cardiac imaging services. Preauthorization can be completed by calling MSI at (888) or online at or FAX (888) AETNA EFT/ERA -Paper-free. The EFT/ERA enrollment is now standard for Aetna -Complete EFT/ERA forms Sign Up for EFT Notification s on NaviNet under Options 47 AETNA OFFICELINK NEWSLETTER -Quarterly updates. -Signup on Navinet under Communications / Newsletters or -National Precertification List. -Clinical Payment, coding and policy changes. -Changes to preferred drug list. -Learning opportunities and more

17 LABORATORY Quest Diagnostics is our national preferred laboratory. It provides tests and services to all Aetna members. Find a convenient location, schedule an appointment and get testing reminders by visiting Quest Diagnostics or calling Your market may also have contracted with local laboratory providers such as: Michigan Joint Venture Hospital Laboratories 49 AETNA STUDENT HEALTH (ASH) NaviNet support eligibility & benefits, claims status inquiry, precertification and referral transactions for members covered under Aetna Student Health plans. AETNA SIGNATURE ADMINISTRATORS (ASA) Providers should direct all ASA claim questions to the appropriate payer on the members card. ASA determines benefits and eligibility. See logo on ID cards below 50 Cofinity Customer Service

18 USING COFINITY S WEBSITE Cofinity s website has many features: Make claims inquiries See repriced amounts Get payer information Access specialty billing rules Find in-network providers Access GH / WC / Auto Participating Payer Lists Updated Quarterly 52 COFINITY WEBSITE View Cofinity s updated website at: for member & claim inquiry, claim activity reports, access payer information, update provider demographic information and other tools. 53 COFINITY WEBSITE 54 18

19 MEMBER CLAIM INQUIRY 55 CLAIMS ACTIVITY REPORT 56 PROVIDER SEARCH FUNCTION 57 19

20 COFINITY BILLING RULES 58 GET CURRENT PRODUCT PAYER LISTS UPDATED QUARTERLY 59 You can also escalate to Cofinity on the website: Go to Cofinity.net / click on a link at the bottom of the page that says Contact Us Select Customer Service option There is a dedicated team of people that work that mailbox on a daily basis

21 CONTACT INFORMATION Aetna Credentialing Aetna Provider Service Navinet Customer Service Cofinity Customer Service Aetna Better Health Secure Provider Web Portal: Aetna Better Health Provider Relations: fax: THANK YOU! QUESTIONS? 62 21