Quality health plans & benefits Healthier living Financial well-being Intelligent solutions October 2016 AAHAM Updates

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions October 2016 AAHAM Updates Debby Synowicki Sr. Provider Relations Representative

2 Aetna s Values Wheel 2

3 Aetna & Coventry Newsletters Stay up to date with quarterly newsletters Aetna OfficeLinkUpdates Located on Health Care Professionals > Newsletters and News. Sign up to have delivered right to your . Coventry Provider News Located within the News section of & Support > Providers, Announcements/News. The October 2016 edition will be the last Coventry Provider News. Past copies will be located on the website for history purposes. 3

4 Provider Office Manuals Aetna and Coventry s provider office manuals are available on our websites and keep you informed Aetna provider office manual Aetna.com > Health Care Professionals > Education & Manuals > Explore provider manuals Navinet.net > Aetna Health Plan > Resources Coventry provider office manual chcnebraka.com > Providers>Document Library > Commercial Guides/Manuals 4

5 Credentialing Aetna uses CAQH to credentialing providers Providers should go to aetna.com > Health Care Professionals > Join the Network If already registered with CAQH, provide the CAQH number when completing the join the network information If you have not registered with CAQH, you will receive a registration kit 7-10 days after submitting your online Aetna application. Credentialing with Aetna, completes credentialing for Aetna, Coventry, Aenta and Coventry Workers Comp, Auto, Aetna Signature Administrators and First Health. Once credentialing is complete, you will receive a notification letter and/or a contract (if needed). Once credentialing and contracting are complete, an effective date will be assigned. Questions about participation MD-Aetna ( ) Check status of credentialing For additional information, please go to -

6 Aetna and Coventry Plans Commercial group POS and PPO employer plans sold in all counties of Nebraska. National PPO employer plans sold in all counties in Nebraska and as a wrap network to Coventry plans who have members residing outside of their local network areas. Commercial group POS and PPO employer plans sold in all counties of Nebraska. Commercial plans will be continuing to transition from Coventry to Aetna through mid

7 Individual & Small Group Plans for 2016 This is an individual Coventry Health Care plan. A full network POS (point of service) option was sold on the Marketplace Exchange. This product was offered to members in all counties except Douglas and Sarpy. This product will no longer be offered in This is an individual & small group Coventry Health Care plan. The Carelink logo means that this is a limited network plan. These plans were offered to members only in Douglas, Sarpy and Pottawattamie counties. These plans will no longer be offered in Aetna Leap plans will be offered. Carelink from CoventryOne - CHI Health Carelink from CoventryOne Nebraska Health Network Carelink from CoventryOne Methodist Health Partners Carelink from CoventryOne - MIPPA 7

8 Individual & Small Group Plans for 2017 This is a small group Aetna ACO narrow network plan. These plans are offered to members only in Douglas, Sarpy and Pottawattamie counties. This product will be offered in Aetna Leap This is an individual & small group Aetna plan. Limited network Aetna Leap plans will be identified in the network name on the member ID card. Limited network plans will be availble beginning 1/1/17 to members in Douglas, Sarpy & Pottawattamie counties. Aetna Leap - CHI Health Omaha Aetna Leap - MIPPA Aetna Leap - Nebraska Health Network This is an HMO product Aetna Leap - Broad Individual and small group plans available in all Nebraska Counties outside of Douglas and Sarpy are offered a full provider network.

9 Rental Network Plans Aetna & Coventry s rental networks. These are networks that various payers access. Attached is a listing of payers accessing the ASA network. For a listing of payers accessing the First Health Network, please log into directprovider.com. As a reminder, you should send all claims for ASA and First Health Network members electronically to the payer ID listed on the member s ID card. Send paper claims only to the address listed on the ID card. Direct all ASA and First Health Network claim questions to the appropriate payer on the ID card. 9

10 Medicare Advantage Plans Coventry and Aetna both have Medicare Advantage Plans. Coventry Advantage plans are sold in Douglas, Sarpy, Cass, Otoe, Gage, Jefferson, Lancaster, Washington, Seward, Butler, Colfax, Dodge, Cuming, Burt & Wayne counties. Coventry Advantage plans will be available to members through 12/31/17 and no longer available as of 1/1/2018. Aetna Medicare is currently available to employers as retiree coverage. Aetna Medicare will be available to all Medicare Advantage members in 1/1/

11 Help members save by staying in network Open enrollment is coming and existing patients may call in with questions about participation with certain plans. Check your participation status Aetna Provider Search - Docfind Aetna.com > Find a Doctor > Select the members plan within your search Coventry Provider Search chcnebraska.com > Find a Doctor > Enter provider search > Select the members plan When referrals are recommended for a consult/procedure, refer members within their specific networks. Also, please make sure that your practice is in network with the members plan prior to seeing the member. Many members have limited provider networks and may have to pay more if they go out of network. See attached handout for additional search instructions 11

12 Digital Aetna Member ID Cards What you need to know about digital member ID cards Why go digital? Digital ID cards are accurate and up to date. They re a more secure source of benefits information. Producing less plastics helps our environment. How can you get a copy of the ID card? NaviNet allows your office to search with out the member ID number and obtain a copy of the most current member ID card. Please see attached handout for additional information and instructions 12

13 National Precertification List (NPL) Aetna and Coventry have one participating provider precertification list as of April 1, 2016 NPL can be found on both aetna.com and chcnebraska.com. Please check the appropriate NPLfor the either Coventry or Aetna, for direction to the appropriate phone numbers, fax or vendor. Updates for 10/1/16 - Services no longer requiring precertification Dialysis services at participating facilities Cochlear implant replacement items Ventricular Assist Device replacement supplies and accessories Following drugs/medical injectables Aloxi IV, Anzemet IV, Jevtana, Aredia, Boniva, Reclast and Zometa For a full listing of all updates and changes please visit view the September 2016 Aetna Office Link Update 13

14 Pharmacy Changes to our commercial drug lists begin on January 1, 2017 On January 1, 2017, our pharmacy plan drug lists (formulary) will change. Starting on September 1, 2016, you can view these changes on our Guides for prescription drug coverage web page located on aetna.com. The changes may affect: All 2017 Pharmacy Management drug lists Precertification program Quantity limits program Step-therapy program Three ways to request a drug precertification: 1. Call the Aetna Pharmacy Precertification unit at Fax your completed prior authorization request form to Submit your completed form through NaviNet. For more information call us at (1-800-AETNA RX).

15 Specialty Drugs & Formularies Specialty drugs precertification update For pharmacy covered specialty drugs on the National Precertification List (NPL), we ve updated our contact information for making your requests. Beginning October 1, 2016, you can reach us in either of the following ways: Call the Aetna Pharmacy Precertification Unit at Fax the completed Specialty Pharmacy Precertification request form to New fax forms are located in the Specialty Pharmacy Precertification section of our Find a form web page on Where to find our Medicare and commercial formularies At least annually, and from time to time throughout the year, we update the Aetna Medicare and commercial (non-medicare) Preferred Drug Lists. These drug lists are also known as our formularies. To find them, go: Aetna.com/Healthcare Professionals/Medicare/Find Prescription Drug Information Aetna.com/Individuals & Families/Find a Medication For a paper copy of these lists, call the Aetna Pharmacy Management Provider Help Line at AETNA RX ( ).

16 Clinical Policy Bulletins Aetna and Coventry both use Aetna s Clinical Policy Bulletins Medical Clinical Policy Bulletins (CPBs) detail the services and procedures we consider medically necessary, cosmetic, or experimental and unproven. View medical and pharmacy Clinical Policy Bulletins (CPBs) online through aetna.com or NaviNet: Aetna.com > Health Care Professional > Clinical Policy Bulletins NaviNet.net > Aetna Health Plan > Resources > Clinical Policy Bulletins 16

17 Payment Policies Clinical payment, coding and policy changes Please view the most current Coventry Provider News and Aetna Office Link Update for a listing of upcoming payment policy changes. View policy information on NaviNet My Health Plans > Aetna Health Plan > Select Claims > Policy Information Claims tools for code editing Payment policies look up Payment and coding policies

18 Aetna Code Editing, Clinical & Payment Policy Lookup Tool Use the Clear Claim Connection tool to determine how a single code or coding combinations (CPT and HCPCS) may be processed. Use this tool to determine: How multiple procedures may be processed If a procedure has limited benefits (for example, cosmetic surgery or experimental or investigational treatments) How modifiers are handled 18

19 Timely Notification for Observation Aetna and Coventry will not be implementing the Timely Notification penalty for Observation stays. If an authorization for Observation over 24 hours is not obtained, the claim will be denied for no authorization. 19

20 Disputes, Reconsiderations & Appeals For additional information on time frames, turn around times, additional levels of appeal or reconsideration, forms or need to know where to send disputes, reconsiderations or appeals please visit > Health Care Professionals > Dispute & Appeals Process >Services & Support > Providers > Document Library > Provider Manual 20

21 Dispute, Reconsideration & Appeals Forms Forms for disputes, reconsiderations and appeals can be found with the following paths - Aetna Forms > Health Care Professionals > Disputes & Appeals > Find dispute and appeal forms Coventry Forms > Services & Support > Providers > Document Library

22 Aetna Provider Service Model Aetna and Coventry would like to remind providers to use the Provider Service Center as a first point of contact for claim issues and questions. Many providers have not been using this method and reaching out directly to Provider Relations. Aetna has begun to reject requests for reprocessing or review of a claim at the request of provider relations; if the provider has not reached out to the service center first. Tips for claims resolution Providers should call the Provider Service Center (PSC) or submit an inquiry through NaviNet for Aetna plans and Directprovider.com for Coventry plans. When talking to a customer service representative in the PSC, please request the claim to be submitted for reprocessing/review. If just checking the claims status the rep will not send the claim through for reprocessing without a request. If providers feel they are not getting the answer from the representative, then please ask for a supervisor. If communicating via secure messaging through the provider portals, please request a supervisor reach out to you and provide your phone number. Write down all reference numbers and names. If after speaking to a customer service representative and supervisor does not correct the issue, then please reach out to Provider Relations and provide reference numbers. Providing the reference numbers and names will help Aetna provide education and track trending issues.

23 2016 Medicare Attestation Complete your 2016 Medicare compliance attestation Annual requirement Each year you must confirm you ve met the Medicare compliance program requirements by completing an attestation. One attestation meets both Aetna and Coventry compliance obligations. Not complying could impact your participation status. The attestation is now available on our secure provider website. If you ve never used NaviNet, log in or register today: Once you log in, go to Aetna Health Plan. Go to Compliance Reporting (on the left) and then click Medicare Attestation. We re here to help If you need more information, you can find educational content on by typing FDR in the search box. Or you can call Disregard this notice if you have completed your 2016 Attestation.

24 Provider Demographic Information How to update data about your office To update your office s demographic information, log on to NaviNet. Please see attached guide for additional instructions on what type of updates are important to update. If you ve been calling our Provider Service Center to make these changes, we ask you to use the secure site instead. The site lets you confirm the information you submit. It prevents unauthorized individuals from submitting wrong information about your office or facility. The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage plans and Qualified Health Plans (QHPs) to maintain accurate directories. Having your up-to-date information allows us to do that. See handout for additional information. 24

25 Coventry Trainings chcnebraska.com

26 Aetna Learning Opportunities 26

27 2016 NaviNet Basic Live Webinars Join us for a free webinar During this one-hour session, we ll demonstrate how to: Register for and navigate our secure provider website supported by NaviNet Identify the role and responsibility of the NaviNet security officer Complete real-time transactions, including: --Eligibility --Payment Estimator --Precertification (including our Precertification Code Search Tool) Access our suite of account management tools: --Claims status inquiry/claims status report --Electronic Explanation of Benefits (including claims reconsiderations) Locate our claims payment and coding resources: --Code Editing, Clinical & Payment Policy Lookup tool --Payment and coding policies You ll also have time to ask questions about how you can use these tools in your office or facility. See attached handout for Webinar session dates and how to register!

28 Thank you