Read PA_Fall_2010_NL_v3.pdf text version

fall 2010 Volume 1, Issue 1

Aetna Better Health Provider Connection

Welcome to aetna Better Health




We welcome this opportunity to introduce ourselves and to thank you for being a part of Aetna Better Health's new network at this exciting and challenging time. Aetna Better Health was selected by the state of Pennsylvania to coordinate benefits and provide access to medical providers for HealthChoices beneficiaries.

Who is aetna Better Health?

Aetna Better Health is Aetna's HealthChoices subsidiary in Pennsylvania. We began operating in April 2010. Aetna Better Health is contracted with more than 4,000 primary care physicians, 8,000 specialists and 52 hospitals in the Southeast and Lehigh/Capital HealthChoices zones. (continued on page 2)


Pharmacy update: how to view our formulary

Aetna Better Health has a wide selection of approved drugs on our Formulary Drug List. The list includes generic prescription drugs and some brand name drugs. Aetna Better Health's provider web portal contains the most up-to-date information about our Formulary Drug List. The formulary list can be found online at In addition to the formulary list, you can view updates, prior authorization guidelines, our specialty drug list, and non-formulary guidelines. If a drug is not on this list and the provider believes the service is medically necessary, the provider must get prior authorization from Aetna Better Health before a pharmacy can fill the prescription. Complete the Non-Formulary Request Form and fax it to Aetna Better Health's Prior Authorization department at 1-877-309-8077.

Welcome to aetna Better Health



Why aetna Better Health?

What makes Aetna Better Health so dynamic? Our Provider Services staff is dedicated solely to our HealthChoices population. These individuals live and work in the counties they serve and are out in the field every day, visiting offices and hospitals, getting to know doctors and office staff.

find helpful information on our provider web portal

Aetna Better Health's convenient and secure HIPAA-compliant provider web portal offers providers and office staff the ability to conveniently perform a variety of transactions. With aetna Better Health's secure provider web portal you can:


Verify member eligibility Identify a member's PCP Download and print up-to-date rosters Receive "HEDIS Interventions Required" notifications for members in the eligibility screens Request prior authorization Check the status of a prior authorization request Verify claim(s) status View and print your remittance advices and verify issued checks


our commitment to you

We look forward to a long and successful working relationship and invite you to share your opinions, advice and comments with us. You can write to the Provider Services Department at: Aetna Better Health 2000 Market Street Suite 850 Philadelphia, PA 19103 or call any of our Provider Services representatives at 1-866-638-1232.







It also contains valuable information such as:


Provider Resources ­ contains forms, guidelines, processes and materials to assist provider offices interaction with Aetna Better Health Searchable Drug Formulary List ­view and download Searchable Provider Directory Provider Manual and Provider Manual updates ­ view and download Application process for new providers in your practice





How to register A user name and password are required to access the secure web portal. During the registration process, providers are asked to assign a Primary Representative from their office. Please visit to download the registration form. User names and passwords are distributed by Aetna Better Health's Provider Relations Department. Provider Relations representatives are available to provide secure web portal training, if needed, via webinar or in your office. We are committed to making the Aetna Better Health website and secure provider web portal easy and efficient for network providers and their staff. To learn how to better use the site, or if you have questions, contact a Provider Relations representative at 1-866-638-1232.

fall 2 0 1 0 | pg 2

Where you can find our prior authorization requirements

Aetna Better Health wants to remind network providers that the list of services that require prior authorization (PA) is located in the provider manual posted on our website at under the provider tab, as well as the prior authorization request form. We currently accept PA requests via our secure web portal, fax and phone. If you would like more information about registration for the web portal, contact the provider relations department at 1-866-638-1232. use appropriate codes When submitting a prior authorization request, Aetna Better Health requires that providers submit specific codes for the services that were performed, as we operate under code-specific prior authorization requirements. If you are a network provider and the services you are performing are not listed on the PA grid then you do not need to submit a request for authorization. If we receive requests that do not require authorization, we will confirm to you that the requested services do not require authorization, and no authorization number will be issued. If you perform a service for which you did not request authorization or the services performed changed from what we authorized, you need to contact the PA unit within two business days after the date of services to update your authorization. All services performed by non-par providers require authorization. You will need to submit your request for PA to include all codes for services being performed. Note that beginning January 1, 2011, Aetna Better Health will only accept authorization requests via fax and the secure web portal. We will continue to accept updates to authorizations via phone, as well as providing status updates on authorization requests by phone. for more information If you have questions regarding services that require authorization, you can call the PA unit at 1-866-638-1232 or Provider Relations at 1-866-638-1232.

Billing tips for submitting claims

Aetna Better Health wants your claim submissions to be simple and efficient, to help ensure that you get prompt and accurate reimbursement. The quickest and easiest way to submit claims is via EDI. Aetna Better Health's Emdeon electronic payer number is 23228. Note these guidelines:


Aetna Better Health has a claim filing limit of 180 days from the initial date of service. Include the J code and NDC code for all pharmacy charges. If you are a Federally Qualified Health Center (FQHC), remember that T1015 is the payable reimbursement code in Aetna Better Health's FQHC fee schedule and is the only billing code we accept for FQHC office visits. All secondary claims must be dropped to paper and submitted with the primary carrier's explanation of benefits. Paper claims should be submitted to:



Topical fluoride Varnish

Effective April 1, 2010, Aetna Better Health will begin coverage for Topical Fluoride Varnish (TFV) treatments provided by properly certified physicians and CRNPs, when provided to Aetna Better Health eligible children under the age of five.


Please bill Aetna Better Health code D1206 for the application of the topical fluoride varnish. The reimbursement for these services will be $18. The maximum number of units that may be reimbursed is four per calendar year.


Procedure code

Place of serVIce






Topical Fluoride Varnish, therapeutic application for moderate to high caries risk patients.


Under 5 years of age; 4 per calendar year.

Aetna Better Health P.O. Box 62198 Phoenix, AZ 85082-2198

If you have any questions, please contact the Aetna Better Health Provider Relations department at 1-866-638-1232.

fall 2 0 1 0 | pg 3

meet your Provider relations contacts

Aetna Better Health's Provider Services team is ready to assist you with any questions, policy or procedural concerns. The Provider Services department is comprised of experienced staff to help you during business hours. If you need help with claim submissions or payment issues, or have questions about Aetna Better Health policies, contact your representative. lebanon, lancaster, dauphin, York, cumberland, Perry and adams counties Shenae Christian Phone - 215-282-3515 | Email ­ [email protected] northampton, lehigh and Berks counties Tamella Williams Phone ­ 215-282-3516 | Email ­ [email protected] Bucks and montgomery counties Plus the following zip codes in Philadelphia: 19101,19102, 19103, 19104, 19108, 19111, 19114, 19115, 19116, 19118, 19119, 19120, 19121, 19122, 19123, 19124, 19125, 19126, 19127, 19128, 19129, 19130, 19132, 19133, 19134, 19135, 19136, 19137, 19138, 19140, 19141, 19149, 19150, 19151, 19152, 19154, 19178, 19184, 19191, 19195 Dawn Choi Phone ­ 215-282-3561 | Email ­ [email protected] chester and delaware counties Plus the following zip codes in Philadelphia: 19106, 19107, 19109, 19110, 19112, 19131, 19139, 19142, 19142, 19143, 19144, 19145, 19146, 19147, 19148, 19153, 19175, 19176, 19181, 19182, 19192 Timothy Marshall Phone ­ 215-282-3558 | Email ­ [email protected]

fall 2 0 1 0 | pg 4

ePsdT billing guide instructions

The purpose of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Billing Guide is to help providers appropriately bill Aetna Better Health using the CMS-1500 claim form or electronically using the 837P format. Providers choosing to bill for EPSDT screens using the CMS-1500 claim form must bill using all of the ageappropriate procedure CPT codes, including immunizations, for a complete screen. screening requirement Screening eligibility information and services require a complete EPSDT screen. Consult the "Provider" section of the Provider Manual at There, you can reference:

n n n n

Recommended Childhood Immunization Schedule as approved by the Advisory Committee on Immunization Practices

Review the instructions below when submitting a CMS-1500 claim form for a complete EPSDT screen. Key


Block Number = Indicates the number as it appears on the CMS-1500 Claim Form. A = Indicates that the claim block must be complete. M = Indicates that the claim block must be completed, if applicable.

Current Pennsylvania's Early and Periodic Screening, Diagnosis and Treatment Program Periodicity Schedule and Coding Matrix

BlocK numBer BlocK name BlocK code noTes


Reserved for local use EPSDT referrals


Enter the applicable two-character EPSDT Referral Code in UPPERCASE / CAPITAL LETTERS for referrals made or needed as a result of the screen: Ym ­ Medical Referral Yd ­ Dental Referral (required for all children 3 years of age and above) YV ­ Vision Referral YH ­ Hearing Referral YB ­ Behavioral Health Referral Yo ­ Other Referral The diagnosis code V20.0, V20.1 or V20.2 (Routine Infant or Child Health Check) must be used in the primary field (21.1) of this block. Additional diagnosis codes should be entered in fields 21.2, 21.3 and 21.4. When reporting immunizations, the appropriate diagnosis codes(s) are required. The code must be one or more of the following: V03.0-V06.9 - Various vaccination codes (see EPSDT Childhood Immunizations Billing Guide for details). Review the CPT codes for services provided and refer to the Periodicity Schedule and Coding Matrix for all required components of a complete EPSDT Screen. Enter the CPT code in the first section of the block then list up to four applicable modifiers in sections two and three.


Diagnosis or nature of illness of injury



Procedures, Services or Supplies (CPT & Modifiers) EPSDT/Family Planning




Enter Visit Code 03 when providing EPSDT screening services.

*Please list all of the required components of an EPSDT screen in Block 24 d on lines 02 through 06. If there are more than six claim lines for a complete EPSDT screen, please use two claim forms.

Note: Failure to bill according to the provided EPSDT Billing Guidelines may result in rejected claims. Contact Aetna Better Health's Provider Relations department or our EPSDT coordinator for any questions regarding the EPSDT program at 1-866-638-1232.

fall 2 0 1 0 | pg 5


5 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate


You might also be interested in

Microsoft Word - GC-7-18.doc
Microsoft Word - DraftILProviderHandbook Version 1.1.doc
Medicaid & CHIP