Read Aetna Doctor's Referral Directory text version

Section III.

Local Network Information

Your Key Regional Contacts

Department Aetna Switchboard You may contact this number for claim office contact information, if the member's ID card is not available. Provider Services HMO Traditional Information on Specialty Networks (e.g., Chiropractic, Laboratory, Radiology, etc) Behavioral Health Precertification of Admissions (24 hours/7 days a week) Contact Information 1-800-US-Aetna or 1-800-872-3862

1-800-624-0756 See Member ID Card 1-800-624-0756 Refer to Local Market Section 1-800-245-1206 ­ HMO 1-800-223-6857 ­ MC/EPO See Member ID Card ­ PPO/TC Please listen for appropriate options 1-800-245-1206 Please listen for appropriate options 1-800-245-1206 Please listen for appropriate options 1-800-245-1206 Please listen for appropriate options

Home Care/Ambulance Transport Nonparticipating Requests Case Management/Utilization Management/Injectable Requests (also: Skilled Nursing Placement and Inpatient Rehab) Radiology Imaging Programs

New Jersey

Greater Metro New York

New England (Includes CT, MA & ME) Physician Credentialing and Application Status

See Phone Numbers Below Please Refer to Market Specific Section for Additional Information Care Core Pre-Cert & Customer Service 1-888-647-5940 Care Core Pre-Cert & Customer Service 1-888-622-7329 MedSolutions Precert & Customer Service 1-888-693-3211 1-800-353-1232

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Local Network Information - Northeast

Northeast Region Behavioral Health Vendor Information

Aetna members may seek treatment from a participating behavioral health professional without obtaining a referral from their primary care physician (PCP). However, the pre-certification through Aetna's behavioral health contractor, is required. Members must contact the behavioral health vendor in order to: · Find a participating behavioral health provider in their area · Obtain pre-certification for mental health and substance abuse services. Precertification Inpatient and Outpatient precertifications are required and can be obtained by the member, the PCP or a behavioral health professional, on the member's behalf. HMO Behavioral Health Contact Information State Connecticut Massachusetts Maine New Hampshire New Jersey New York(except Bronx) New York (Bronx) Rhode Island Service Vendor Phone Number Behavioral Health Connecticut 1-877-593-5061 Magellan 1-800-424-6108 Magellan 1-800-538-3859 Magellan 1-800-424-5726 Magellan 1-800-424-5964 Magellan 1-800-755-2422 University Behavioral Associates 1-800-401-4822 Magellan 1-800-424-6130 Traditional Behavioral Health Please contact the phone number located on the member's ID Card.

Members should follow the guidelines below when seeking mental health and substance abuse services: · Contact the vendor first so they can pre-certify and arrange all routine, urgent and emergency behavioral health and substance abuse services. In an emergency, the member should seek care immediately. If a member needs to go to an emergency room for a mental health or substance abuse crisis, please contact the vendor for assistance in managing the admission and any referrals for additional behavioral health services that may be needed. Although a PCP referral is not needed for these types of emergency room services, the members PCP should be notified. Please Note: Because a PCP referral is no longer necessary for mental health and substance abuse services, it is very important that the member contact MBH to obtain necessary authorizations and referrals for these types of services. Also Note: Some employers may have selected a Behavioral Health Contractor other than those above to manage their Behavioral Health benefits. If you have any questions with regard to the Behavioral Health Contractor for a member, contact Aetna provider services at 1-800-624-0756 or the number listed on your patient's member ID card for Traditional products.

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Local Network Information - Northeast

Capitated Programs

Capitated programs apply to Aetna HMO, QPOS, US Access, Open Access HMO, Aetna Choice POS and Golden Medicare plans only, when available in a local market. Aetna has established capitation programs for certain outpatient specialties. Each capitated provider is contracted to provide a full range of services and can be identified by PCPs as the vendor of choice for Aetna members by contacting our physician service area at 1-800-624-0756. The capitated programs may include the following services:

Program Descriptions

Laboratory When a PCP or a specialist requires laboratory testing on an outpatient basis, a capitated laboratory should be utilized whenever possible. The capitated laboratory will conduct an office orientation and establish an account with the physician office. Accurate billing is improved by ensuring the following information in included on the laboratory requisition form. o o o o o o Physical Therapy Patient name (as it appears on the member ID card) Member ID Number Patient Address Patient Date of Birth Patient Gender Patient IDC-9 code

Primary care physicians may select a capitated physical therapy provider when this program is available in your area. The physical therapy provider will provide a full range of physical therapy and occupational therapy services. The capitation covers ages 12 and above. Children under age 12 may be referred to your capitated physical therapy provider or any participating provider. Please refer to the Aetna Referral Directory for the current list of physical therapy providers. If your market does not have a capitated physical therapy provider, the member should be referred to a participating physical therapy provider.

Foot Care

Primary care physicians may select only one Aetna participating capitated foot care provider. All foot care services must then be referred to the PCP's capitated provider. Participating pediatricians may also select a capitated foot care provider; however, foot care is not capitated for children under 12 years of age.

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Local Network Information - Northeast

Aetna Golden Medicare members are also capitated for foot care. Radiology Radiology studies require an authorization or referral in Massachusetts, Maine, Connecticut, New York and New Jersey. Please see Region tab for further information. Primary care physicians may select only one capitated radiology provider. All nonemergent outpatient diagnostic radiology services must then be directed to this radiology provider. Capitated radiology services do not include stress thallium studies, or obstetrical ultrasounds, and in some cases, MRI services. Participating providers must be used when ordering any radiology study. See your Aetna Referral Directory for a listing of these locations. Radiology studies, including MRI and MRAs, can be ordered by either the primary care physician or participating specialist; however, the member must be sent to the radiologist their PCP has selected for capitated services. The following vendors have been selected to provide imaging precertification: Vendor Care Core Inc. Med-Solutions Inc. Service Area Metro New York and New Jersey * Connecticut, Massachusetts and Maine

* Excluding Upstate New York (e.g., North and West of, and including Delaware, Greene and Columbia counties).

. Please reference the market specific section in this Toolkit for state specific quick reference guides that include county listings.

Please Note: If your area does not have access to capitated providers, the member should always be referred to a participating provider. Please check your Aetna Physician Referral Directory for a listing of participating providers.

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Local Network Information - Northeast

Chickering Student Health Program

Aetna partners with The Chickering Group, our exclusive TPA for Student Health Plans, to provide health coverage for college students. These Student Health Plans are underwritten by Aetna, but administered by Chickering on a separate claim system, due to the intricacies of these plans. All Student Health Plans utilize our Aetna network and utilization review staff. Chickering handles provider service calls as well at 800-966-7772. For more information on Chickering, please visit their website at: www.chickering.com. Currently, claims are only accepted via paper by direct submission to: The Chickering Group PO Box 15708 Boston, MA, 02215-0014 Should you have questions or need clarification, please contact the number on the member's ID card.

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Local Network Information - Northeast

Physician Billable Services ­ HMO Plans

Capitated Primary Care Physicians Only

The Aetna capitation model expands the number of services for which Aetna will reimburse primary care physicians (PCPs) on a fee-for-service basis outside of the monthly capitation payment. For instance, fee-for-service payments will be made for minor surgical procedures, endoscopies, immunizations, fracture care, stat laboratory services and certain other officebased procedures in accordance with Aetna's claims submission and adjudication policies and procedures.

Limited In-Office Laboratory and Radiology Services

All physicians may provide certain laboratory and radiology procedures in their office and these services will be reimbursed by Aetna on fee-for-service basis. This policy allows physicians who are properly certified to conveniently provide certain laboratory and radiology services on a stat or as needed basis within their offices. Please refer to the schedule previously distributed for details on these billable services. If needed, laboratory and radiology should be directed to contracted specialty sites. Referrals are not required in these circumstances. For further information on these policies, please contact Aetna provider services at 1-800624-0756.

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Local Network Information - Northeast

GREATER METROPOLITAN NEW YORK

CARE CORE NATIONAL and AETNA DIAGNOSTIC IMAGING PROGRAM QUICK REFERENCE GUIDE

Phone Numbers: · CareCore Precert line: 1-888-622-7329 (8:00 am - 6:00 pm) · CareCore Customer Service: 1-888-622-7329 (8:30 am ­ 5:00 pm) · CareCore fax line: 1-845-298-1490 · Aetna Provider Services: 1-800-624-0756 Imaging Care Management (Precertification): Required for each of the following procedures: CT Scans Nuclear Medicine MRI/MRA Pet Scans (See complete list of CPT codes) Exclusions: Above procedures performed in the following place of service: · Inpatient setting · Emergency room · Ambulatory surgery center (SPU) Information required for a Complete Precertification Request: 1. Patient Information: · Health Plan name · Patient's Aetna ID number · Patient name · Date of Birth · Address · Telephone number 2. Medical Identifiers: · Ordering physician's name, specialty, address, and telephone number · Facility to which the patient is being referred and its address · The contact person at the ordering physician's office 3. Clinical Information: · The examination(s) being requested, with the CPT code(s) · The diagnosis or "rule out" with the ICD-9 code(s) · The patient's symptoms, listed in detail, with severity and duration. Any treatments that have been tried, including dosage and duration for drugs, and dates for other therapies. · Any other information that the physician believes will help in evaluating the request, including but not limited to prior diagnostic tests, consultation reports, etc. · Dates of prior imaging studies performed. Claims Submission · All claims for radiology services will be submitted to Aetna as they are today. · Physicians/radiology providers who are directly contracted with CareCore should bill them directly. · All current reimbursement policies and procedures will apply. · Any claims for services requiring a precertification that has either not been obtained or was not approved in advance, will be denied · Services billed for any procedure (CPT code) other than those approved will be denied. · Members must not be billed for any services denied due to the lack of an approval or valid precertification. · Obtaining an approved precert does not guarantee payment. Claims payment is also dependent upon the member's eligibility and benefit plan. · Physicians and/or radiology providers should

Eligibility Verification: Process below is detailed in the "Aetna Participating Physician Office Manual" Aetna ID Card At each visit, the office should ask to see the member's ID card to verify eligibility and to collect appropriate co-payment. To Check Eligibility: Offices may use one of the following options · VRU-Voice Response Unit · POS/Genesis Device · Practice Management Software · EDI Vendor Internet Portal · Aetna's Provider Relations Phone Line: 1800-624-0756

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Local Network Information - Northeast

Service Area: Members residing in, but have not yet selected PCPs, as well as those who have selected PCPs located in the following counties: Westchester, Manhattan, Bronx, Kings (Brooklyn), Queens, Richmond (Staten Island), Nassau, Suffolk, Rockland, Orange, Putnam, Dutchess, Ulster, and Sullivan. Products Included: All HMO based plans including, but not limited to- HMO, QPOS®, US Access®, Aetna Open AccessTM, Individual Advantage, and Effective 4/1/03: Aetna Golden Medicare Plans® Members Excluded: Certain multi-specialty or IPA groups. Imaging Care Management Process Physicians will obtain a precert by contacting CareCore: By phone: 1-888-622-7329 or Fax: 845-298-1490 (fax form enclosed) · Physician must provide all information listed on this card for a precert request to be reviewed. · The patient's clinical history and diagnostic information will determine if the requested procedure meets the medical criteria for each procedure requested. · All decisions are made by licensed, health care professionals. · Review determinations for non-urgent care will be completed within two (2) working days of receipt of all the necessary information. · Requesting physicians will be notified of review determinations (see outcomes section). Physician and radiology providers may verify precert status by calling CareCore on the precert line above or over the Internet @ www.carecorenational.com Urgent Cases: Physicians may request authorization on an urgent basis if they determine it to be medically required. Decisions will be rendered for urgent requests within three (3) hours of CareCore receiving all required information. Retrospective Reviews If services are required on an urgent basis

contact either Care Core or Aetna at the numbers listed above. Complaints and or Grievance · Members, physicians or radiology providers may register a complaint with Aetna by calling Member Services at the toll-free number on the Member's Aetna ID card or Provider Services at 800 6240756. · If the member/provider is not satisfied with the response received, the Member or Provider Services staff can explain the Aetna grievance process that applies to their benefit plan.

Imaging Care Management Review Outcomes: · Approvals: Requests, which satisfy all of the criteria for medical necessity, will be approved. Approvals will be communicated both telephonically and in writing to the referring physician with an accompanying authorization number · Withdrawal: In the event that the requesting provider agrees that the request for service is not the appropriate exam, the requesting physician may withdraw his/her request for clinical certification. · Written notification will be sent to the physician acknowledging the withdrawal. Non-certified: (Adverse Determination) Studies that do not meet criteria for medical necessity will be denied. · Prior to a final decision being rendered additional clinical information to support the medical necessity of the procedure may be requested from the referring physician. · The requesting physician will be notified by telephone as the patient designee. The patient and physician are notified by mail, as required by law, of the adverse determination. · Notification will include information as to why the procedure was denied and what appeal rights the member has. · Reconsiderations: physicians who have additional information may request a reconsideration from CareCore of the adverse determination. · Decisions may also be appealed as outlined below · Appeals ­ Members, for whom a procedure has

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Local Network Information - Northeast

and authorization cannot be obtained, the procedure may be performed, and an authorization requested retrospectively. · Requests for a retrospective review must be made within two (2) business days of the date of service. · Physicians should follow the same process outlined above for a standard request. · Documentation must include why the procedure was required on an urgent basis. · Clinical justification for the request will be reviewed using the same criteria as a routine request. · Retrospective review decisions will be made within thirty (30) working days of receiving all necessary information. (Note: if the procedure does not meet medical necessity guidelines payment will be denied.)

been denied, have the right to appeal. Physicians may also file an "appeal" (see appeal section) regarding decision that request does not meet criteria. · Appeals may be initiated by the member, or the referring physician on the member's behalf · The process for filing an appeal can be obtained by calling Aetna's Member/Provider Services. o Provider Service- 1-800-624-0756 o Member Services ­ 1-800-323-9930 or the number on the back of the member's card. · Additionally, appeals can be filed by following the directions indicated on the denial letter.

08.03.80.1-NY

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Local Network Information - Northeast

No. New Jersey NYMI now CareCore

AETNA DIAGNOSTIC IMAGING PROGRAM QUICK REFERENCE GUIDE

Phone Numbers: · CareCore Precert line: 1-888-647-5940 (8:00 am - 6:00 pm) · CareCore Customer Service: 1-888-647-5940 (8:30 am ­ 5:00 pm) · CareCore fax line: 1-845-298-1490 · Aetna Provider Services: 1-800-624-0756 Imaging Care Management (Precertification): Required for each of the following procedures: CT Scans Nuclear Medicine MRI/MRA Pet Scans (See complete list of CPT codes) Exclusions: Above procedures performed in the following place of service: · Inpatient setting · Emergency room · Ambulatory surgery center (SPU) Information required for a Complete Precertification Request: 1. Patient Information: · Health Plan name · Patient's Aetna ID number · Patient name · Date of Birth · Address · Telephone number 2. Medical Identifiers: · Ordering physician's name, specialty, address, and telephone number · Facility to which the patient is being referred and its address · The contact person at the ordering physician's office 3. Clinical Information: · The examination(s) being requested, with the CPT code(s) · The diagnosis or "rule out" with the ICD-9 code(s) · The patient's symptoms, listed in detail, with severity and duration. Any treatments that have been tried, including dosage and duration for drugs, and dates for other therapies. · Any other information that the physician believes will help in evaluating the request, including but not limited to prior diagnostic tests, consultation reports, etc. · Dates of prior imaging studies performed. Claims Submission · All claims for radiology services will be submitted to Aetna as they are today. · All current reimbursement policies and procedures will apply. · Any claims for services requiring a precertification that has either not been obtained or was not approved in advance, will be denied · Members must not be billed for any services denied due to the lack of an approval or valid precertification. · Obtaining an approved precert does not guarantee payment. Claims payment is also dependent upon the member's eligibility and benefit plan. · Physicians and/or radiology providers should contact either their Professional Services Coordinator (PSC) or Network Services Coordinator (NSC) with any questions.

Eligibility Verification: Process below is detailed in the "Aetna Participating Physician Office Manual" Aetna ID Card At each visit, the office should ask to see the member's ID card to verify eligibility and to collect appropriate co-payment. To Check Eligibility: Offices may use one of the following options · VRU-Voice Response Unit · POS/Genesis Device · Practice Management Software · Web MD Office (internet) · Aetna's Provider Relations Phone Line: 1-800-624-0756

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Local Network Information - Northeast

Service Area: Members enrolled to PCPs located in the following counties: Bergen, Essex, Hudson, Hunterdon, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset, Sussex, Union and Warren Products Included: All HMO based plans including, but not limited to- HMO, QPOS®, US Access®, Aetna Open AccessTM, Individual Advantage, Golden Medicare Plans Imaging Care Management Process Physicians will obtain a precert by contacting CareCore: By phone: 1-888-647-5940 or Fax: 1-845-298-1490 (fax form enclosed) · Physician must provide all information listed on this card for a precert request to be reviewed. · The patient's clinical history and diagnostic information will determine if the requested procedure meets the medical criteria for each procedure requested. · All decisions are made by a New Jersey licensed, board certified physician.. · Review determinations for non-urgent care will be completed within two (2) working days of receipt of all the necessary information. · Requesting physicians will be notified of review determinations (see outcomes section). Physician and radiology providers may verify precert status by calling CareCore on the precert line above or over the Internet @ www.carecorenational.com Urgent Cases: Physicians may request authorization on an urgent basis if they determine it to be medically required. Decisions will be rendered for urgent requests within three (3) hours of CareCore receiving all required information. Retrospective Reviews If services are required on an urgent basis and authorization cannot be obtained, the procedure may be performed, and an authorization requested retrospectively. · Requests for a retrospective review must be made within two (2) business days of the date of service. · Physicians should follow the same process outlined above for a standard request. · Documentation must include why the procedure was required on an urgent basis.

Complaints and or Grievance · Members, physicians or radiology providers may register a complaint with Aetna by calling Member Services at the toll-free number on the Member's Aetna ID card or Provider Services at 800 6240756. · If the member/provider is not satisfied with the response received, the Member or Provider Services staff can explain the Aetna grievance process that applies to their benefit plan. Imaging Care Management Review Outcomes: · Approvals: Requests, which satisfy all of the criteria for medical necessity, will be approved. Approvals will be communicated both telephonically and in writing to the referring physician with an accompanying authorization number · Withdrawal: In the event that the requesting provider agrees that the request for service is not the appropriate exam, the requesting physician may withdraw his/her request for clinical certification. · Written notification will be sent to the physician acknowledging the withdrawal. Non-certified: (Adverse Determination) Studies that do not meet criteria for medical necessity will be denied. · Prior to a final decision being rendered additional clinical information to support the medical necessity of the procedure may be requested from the referring physician. · The requesting physician will be notified by telephone as the patient designee. The patient and physician are notified by mail, as provided by law, of the adverse determination. · Notification will include information as to why the procedure was denied and what appeal rights the member has. · Reconsiderations: physicians who have additional information may request reconsideration from CareCore of the adverse determination. Reconsiderations must be filed within 3 days of the notice of the denial. Physicians, who have additional documentation to support the denied request after the 3 days can appeal through the Aetna appeals process. · Decisions may be appealed as outlined below · Appeals ­ Members, for whom a procedure has been denied, have the right to appeal. Physicians may also file an "appeal" (see appeal section) regarding decision that request does not meet criteria. · Appeals may be initiated by the member, or the

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Local Network Information - Northeast

· Clinical justification for the request will be reviewed using the same criteria as a routine request. Retrospective review decisions are made within thirty (30) working days of receiving all necessary information. However, in general, CareCore completes retrospective reviews within 2 business days. (Note: if the procedure does not meet medical necessity guidelines payment will be denied.)

referring physician on the member's behalf · The process for filing an appeal can be obtained by calling Aetna's Member/Provider Services. o Provider Service- 1-800-624-0756 o Member Services ­ 1-800-323-9930 or the number on the back of the member's card. · Additionally, appeals can be filed by following the directions indicated on the denial letter.

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Local Network Information - Northeast

Aetna Unique Specialty Providers ­ HMO and QPOS Connecticut

Laboratory: Quest This specified provider should be utilized for all laboratory services (primary and specialist requests). If the indicated laboratory provider is unable to perform a specific test, please have the member go to that provider anyway to have the blood drawn and have the lab determine which facility the sample should be sent to for testing. A referral is not necessary as long as the lab's requisition form is utilized and the member presents an Aetna ID card.

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Local Network Information - Northeast

Massachusetts and New Hampshire Immunization Policy

As part of Aetna's immunization program, we are committed to working closely with participating primary care physicians to improve the overall immunization rate for our pediatric membership. The states of Massachusetts and New Hampshire are universal vaccine distribution states that provide all recommended childhood vaccines free of charge, including tetanus-diphtheria (TD) vaccines, to their residents. Aetna reimbursement policy covers only the administration fee for recommended childhood vaccines and TD that can be supplied by either the Massachusetts Immunization Program (MIP) or the New Hampshire Immunization Program (NHIP). To enroll and obtain these free vaccines for your patients, please call one of the following, depending on your location: Massachusetts Immunization Program ­ 617-983-6828. - OR New Hampshire Immunization Program ­ 603-271-4634 In order to be reimbursed for the administration fee, please submit claims electronically or on a HCFA 1500 form with the appropriate vaccine code and our claim systems will reimburse you for the administration fee. Please note: · Claims for HMO members should be submitted to PO Box 1125, Blue Bell, PA 19422. · Claims for Non HMO Members (i.e. Open Choice, Managed Choice, Elect Choice and Traditional Choice) should be sent to the appropriate claim address listed on the back of the member's ID card. Should you have questions on the above information, please contact Aetna provider services at 1-800-624-0756.

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Local Network Information - Northeast

Radiology Imaging Program: MedSolutions Massachusetts / Maine / Connecticut

Aetna Radiology Management Program: MedSolutions Aetna requires that all outpatient, elective MRI, MRA, CT scans, PET scans, and nuclear cardiac imaging studies demonstrate medical necessity through precertification with MedSolutions. Radiology procedures performed during an inpatient or emergency room visit do not require precertification with MedSolutions. Medical review can require 24 hours or one business day for completion. Please keep these time frames in mind when scheduling studies that require precertification. This program affects most Aetna HMO, QPOS®, Aetna Open AccessTM HMO, Aetna ChoiceTM POS and USAccess® members with a Maine, Massachusetts or Connecticut based Primary Care Physician. For those physicians participating with Aetna through an Independent Physician Association (IPA) Agreement, the precertification policy for members with a primary care physician associated with the IPA may differ. Please contact your contract negotiator or physicians relations liaison (PRL) for further details. Precertification Process There are three separate ways to request precertification of an imaging procedure from MedSolutions: Complete the Internet-based submission form by logging on to the secure website at www.medsolutions.com or 2. A) Complete the demographics box at the top of the Universal CT/MRI form and include the office notes/previous imaging reports for the patient or B) complete the appropriate fax form by body part in its entirety, and fax to MedSolutions tollfree at 1-888-693-3210 or 3. Call MedSolutions toll-free at 1-888-693-3211 and give all pertinent clinical information over the telephone. When calling MedSolutions with a request for precertification, please have the following information available: · · · Approvals Your request for precertification will be processed within 24 hours or one business day after the receipt of all necessary clinical information. Once a requested procedure is approved, an authorization number will be faxed to the ordering physician and requested facility, and mailed to the member. Patient demographic information from the top of the fax form. Current diagnosis and clinical information, including treatment history, treatment plan and medications. The patient's chart and previous imaging study results 1.

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Local Network Information - Northeast

Denials Prior to a denial, the ordering physician will be given an opportunity to discuss the treatment plan and clinical basis for the request. If the requested procedure is then denied, a MedSolutions representative will contact the ordering physician's office and verbally communicate that the procedure has been denied and the rationale for the denial. Written notification of the denial will be faxed to the ordering physician and the facility requested to perform the procedure. The denial determination will be mailed to the patient following the adverse decision. The written notification will include details addressing the right to an appeal. Denial Decision Physician Discussions The treating physician may request to have a discussion regarding the denial decision for an individual case with a MedSolutions' physician reviewer by calling MedSolutions at 1-888-6933211. Physician Consultations MedSolutions has a staff of physicians that can be reached by phone to provide assistance in determining the most appropriate imaging study for your patient. You can access this resource by calling 1-888-693-3211 and pressing the option for physician consultation. Please be sure to have the patient identification number and the applicable clinical information available at the time of the call. Medically Urgent Outpatient Procedures For medically urgent services, call MedSolutions toll-free at 1-888-693-3211 for precertification. Have the pertinent clinical office notes, the patient's chart and previous imaging study results available for reference during your call. MedSolutions will make a good faith effort to render a medical necessity decision within 4 hours of receipt of all necessary clinical information. Please clearly indicate that the precertification request is medically urgent. Facilities/Radiologists Please call MedSolutions at 1-888-693-3211 to verify the status of the request, if a member presents for testing without proof of precertification. The precertification number should also be entered on the billing form to ensure accurate payment of the claim. MedSolutions Web-Based Services You may access MedSolutions on-line for day-to-day transactions and services. To reach MedSolutions on-line services, please go to the website, www.medsolutions.com and click the MedSolutions Online link. Here you may sign up for access to a suite of MedSolutions services, including precertification status inquiry and medical guidelines. Please click the "First Time User Help" link for details about MedSolutions Online and how to become a member. Please be sure to watch the website for news of future online initiatives. Fax Forms You can print additional copies of the fax forms for your use by accessing MedSolutions' website at www.medsolutions.com/faxforms.htm or by calling the MedSolutions Account Manager toll free at 1-888-295-2954.

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Local Network Information - Northeast

Maine Chiropractic Care (Subluxation Benefits)

For access to chiropractic care, the Aetna Health Inc.'s Chiropractic Care Benefit complies with Maine State mandate, as follows: A member may self-refer to a participating chiropractic provider, without a referral, if the member needs acute chiropractic treatment. "Acute chiropractic treatment" is defined as treatment by chiropractic provider for accidental bodily injury or sudden, severe pain that impairs the person's ability to engage in the normal activities, duties or responsibilities of daily living. Self-referred acute chiropractic treatment is covered if all of these conditions are met: · · · The injury or pain requiring acute chiropractic treatment occurs while the member's coverage under the Aetna plan is in effect; Acute chiropractic treatment is provided by a participating chiropractor; The participating chiropractic provider prepares a written report of the member's condition and treatment plan, including any relevant medical history, the initial diagnosis and other relevant information. Note: The chiropractic provider must send the report and treatment plan to the primary care physician within three (3) business days of the member's first treatment visit. If the chiropractic provider does not follow this requirement, Aetna Health Inc. will not cover acute chiropractic treatment provided by the chiropractic provider, nor will the member be required to pay for services. Coverage for self-referred acute chiropractic treatment is limited to an initial maximum treatment period lasting until the last day of the third week from the member's first treatment visit, or the twelfth treatment visit, whichever occurs first. At the end of this initial treatment period, the chiropractic provider will determine whether the services provided during this initial treatment period have improved the member's condition. Aetna Health Inc. will not cover self-referred acute chiropractic treatment provided after the point at which the chiropractic provider determines that the member's condition is not improving from the services. At this point, the chiropractic provider must discontinue treatment and refer the member to the member's primary care physician. If the chiropractic provider recommends further acute chiropractic treatment, Aetna Health Inc. will cover this further treatment up to the limits specified below, but only if he or she sends a written progress report of the member's condition and a treatment plan to the member's primary care physician before any further treatment is provided. If the chiropractic provider fails to follow this requirement, Aetna Health Inc. will not cover any further acute chiropractic treatment in connection with the same illness or injury causing the member's condition. The coverage for this further acute chiropractic treatment is limited to a maximum treatment period lasting until the last day of the fifth week from the member's first further treatment visit, or the twelfth further treatment visit, whichever occurs first. Coverage for all self-referred acute chiropractic treatment is limited to a maximum of 36 treatment visits during any consecutive 12-month period.

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Local Network Information - Northeast

Aetna's Medicare+Choice Plans (NY & NJ)

Aetna contracts with the Centers for Medicare & Medicaid Services (CMS) to offer two Medicare+Choice (M+C) plan options in five states for 2003, and, as such, it is an M+C organization (M+CO). The M+C plan options offered in 2003 are known as the "Aetna Golden Medicare Plan" (a managed care plan) and the "Aetna Golden Choice Plan" (an open access managed care plan with a point of service option). Generally, all M+C plans are required to offer Medicare basic benefits and follow both national and local coverage decisions. Members of the Aetna Golden Medicare Plan are required to select a primary care physician. Except for those benefits described in the member's plan documents as direct access benefits and emergent or urgent care, members must have a referral from their primary care physician to receive coverage for any services the specialist or facility provides. (Offered in select counties in CA, NJ, NY, and PA.) Members of the Aetna Golden Choice Plan are not required to select a PCP or obtain a referral in order to obtain services from a network doctor, network specialist or network hospital. Aetna Golden Choice Plan members also have the option to select any non-network doctor, specialist or hospital for covered services without a referral. If exercising this option, they share the cost of their out-of-network medical expenses in the form of deductibles and coinsurances. (Offered in select counties in MD, NJ, and PA.)

Physician/Health Care Professional Responsibilities & Important Information In accordance with M+C laws, rules and regulations, the following requirements apply to physicians or health care professionals (and their employees, independent contractors and subcontractors) contracting with a M+CO ("contracting providers"): Access to Facilities and Records M+C rules and regulations require that contracting providers retain and make available all records pertaining to any aspect of services furnished to M+C plan members for inspection, evaluation and audit for the longer of six years from the termination date of the provider's contract with Aetna or the period required by law. Access to Services Aetna has procedures to: Identify members with complex or serious medical conditions; Assess those conditions, using medical procedures to diagnose and monitor them on an ongoing basis; and Establish a treatment plan with an adequate number of direct access visits to specialists (e.g., no prior authorization required) to comply with the treatment plan. Aetna's contracting providers are required to make services available in a culturally competent manner to all M+C members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities. Aetna maintains procedures to inform members with specific health care needs of follow-up care and provide training in self-care, as necessary. Advance Directives Aetna's contracting providers must document in a prominent place in an M+C member's medical record whether the member has executed an Advance Directive. Please refer to the Member Rights and Responsibilities section for more information on Advance Directives.

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Aetna's Medicare+Choice Plans

Appeals & Grievances Aetna may require the cooperation and/or participation of contracting providers in Aetna's internal and external review procedures relating to the processing of Medicare appeals and grievances. If necessary, the provider should instruct the member to contact the health plan for his or her M+C appeal rights as well as inform the member of his or her right to receive, upon request, a detailed written notice from the health plan regarding coverage for services. Members should be directed to contact Member Services using the phone number listed on their ID card. Confidentiality and Accuracy of Enrollee Records Aetna's contracting providers must safeguard the privacy and confidentiality of and assure accuracy of any information that identifies a M+C plan member. Original medical records must be released only in accordance with federal or state laws, court orders or subpoenas. Aetna's contracting providers must: Maintain accurate medical records or other health information, Help ensure timely access by members to the records and information that pertains to them, and Abide by all federal and state laws regarding confidentiality and disclosure of mental health records, medical records, other health information and member information. Please refer to the Privacy Practices section for further information. Coverage of Renal Dialysis Services for Medicare Members Temporarily Out of Area An M+C plan member may be temporarily out of the service area for up to six months. M+COs must pay for renal dialysis services obtained by an M+C plan member from a contracted or noncontracted Medicare-certified physician or health care professional while the member is temporarily out of the M+C plan's service area. Direct Access to In-Network Women's Health Specialists M+C members have direct access to mammography screening services at a contracted radiology facility without a referral, as well as direct access to in-network women's health specialists for routine and preventive services. Emergency Services Please refer to the Office Management section for more information on Emergency Services. Health Risk Assessment Aetna performs an initial health risk assessment of each new M+C enrollee within 90 days of enrollment in an Aetna M+C plan. A health risk assessment survey is completed by telephone for all new M+C plan members. The information obtained through the survey is sent to the member's primary care physician. No Cost-Sharing for Influenza and Pneumococcal Vaccines M+C plan members are not required to pay an office visit copayment if the administration of an influenza or pneumococcal vaccine is the only service provided. Receipt of Federal Funds, Compliance with Federal Laws & Prohibition on Discrimination Payments made by Aetna to a contracting provider for services rendered to an M+C member constitute receipt of federal funds; therefore, an M+CO's contracting providers are subject to: (1) Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 84; (2) the Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91; (3) the Rehabilitation Act of 1973; (4) the Americans With Disabilities Act; and (5) all other laws applicable to recipients of federal funds. In addition, Aetna's contracting providers must comply with all applicable Medicare laws, rules and regulations and they are prohibited from discriminating against a M+C member on the basis of health status.

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Aetna's Medicare+Choice Plans

Physician Terminations CMS requires that M+C plans make a good faith effort to provide written notice of a termination of a contracted physician at least 30 calendar days before the termination effective date to all members who are patients seen on a regular basis by the physician (e.g., specialist) whose contract is terminating. In addition, when a contract termination involves a PCP, all members who are patients of that primary care professional must also be notified. Financial Liability for Payment for Services In no event shall an M+CO's contracting providers bill an M+C member for payment of fees that are the legal obligation of the M+CO. However, a contracting provider may collect deductibles, coinsurance or copayments from M+C members in accordance with the terms of the member's agreement with Aetna. Temporary Move Out of the Service Area CMS defines a temporary move as (1) an absence from the service area (where the member is enrolled in an M+C plan) of six months or less, and (2) maintaining a permanent address/residence in the service area. An M+C plan member is covered out of the service area for emergency, urgent, and out-of-area dialysis services. A member who moves out of the M+C service area for over six months is disenrolled from the M+C plan. Urgently Needed Services Urgently needed services are covered services provided when a member is temporarily absent from the plan's service area (or, under unusual and extraordinary circumstance, provided when the member is in the service area but the plan's physician network is temporarily unavailable or inaccessible) when such services are medically necessary and immediately required. The need for such services could be the result of an unforeseen illness, injury, or condition, when it was not reasonable, given the circumstances, to obtain the services through the health plan. Physicians and Health Care Professionals & Marketing of M+C Plans M+COs and their contracting providers must adhere to all applicable M+C laws, rules and regulations relating to marketing. Per M+C regulations, "marketing materials" includes, but is not limited to, promoting an M+CO or a particular M+C plan, informing Medicare beneficiaries that they may enroll or remain enrolled in an M+C plan offered by an M+CO, explaining the benefits of enrollment in an M+C plan or rules that apply to enrollees, or explaining how Medicare services are covered under an M+C plan. Physicians and other health care professionals may discuss, in response to an individual patient's inquiry, the various benefits of M+C plans. Physicians and health care professionals can refer their patients to 1-800-MEDICARE, the State Health Insurance Assistance Program, the specific health plan M+C marketing representatives or CMS's website at www.medicare.gov in order to obtain additional information. Physicians and health care professionals cannot accept M+C plan enrollment forms. Services Received Under Private Contract Pursuant to the Balanced Budget Act of 1997 (BBA), physicians may "opt out" of participating in the Medicare program and enter into private contracts with Medicare beneficiaries. If a physician chooses to opt out of Medicare due to private contracting, no payment can be made to that physician directly or on a capitated basis for Medicare-covered services. The physician cannot choose to opt out of Medicare for some Medicare beneficiaries but not others, or from some services but not others. The M+CO is not allowed to make payment to any physicians or health care professionals who have opted out of Medicare due to private contracting, unless the beneficiary was treated for urgent or emergent care. Claims/Billing Requirements Physicians and health care professionals must use valid International Classification of Disease, 9th Edition, Clinical Modification (ICD-9 CM) codes and code to the highest level of specificity.

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Aetna's Medicare+Choice Plans

Complete and accurate use of CMS's Healthcare Common Procedure Coding System (HCPCS) and Common Procedural Terminology, 4th Edition, (CPT) procedure codes are also required. Hospitals and physicians using the Diagnostic Statistical Manual of Mental Disorders, 4th Edition, (DSM IV) for coding must convert the information to the official ICD-9 CM codes. Failure to use the proper codes will result in diagnoses being rejected in the Risk-Adjustment Processing System. The ICD-9 CM codes must be to the highest level of specificity: assign three-digits codes only if there are no four-digit codes within that code category, assign four-digit codes only if there is no fifth-digit sub-classification for that subcategory, assign the fifth-digit sub-classification code for those subcategories where it exists. Report all secondary diagnoses that impact clinical evaluation, management and/or treatment. Report all relevant V-codes and E-codes pertinent to the care provided. An unspecified code should not be used if the medical record provides adequate documentation for assignment of a more specific code. Failure to use current coding guidelines may result in a delay in payment and/or rejection of a claim. Submission of Medicare Claims and Encounter Data The BBA mandates M+COs to collect and submit claims and encounter (risk-adjustment data) to CMS that is received from hospitals, outpatient departments, physicians and certain nonphysician practitioners. Prior to 2002, CMS only collected inpatient hospital claims and encounters from the health plans. Physicians and health care professionals are required to submit accurate, complete and truthful data to the M+COs. Risk-adjustment data submitted will determine risk-adjusted premium payments from CMS to the M+COs. Prior to the enactment of the BBA, the payment rate was 100 percent demographic. Beginning January 2000, the payment model changed to a blended rate of 10 percent risk adjustment and 90 percent demographic. This blended rate will continue through 2003. The percentage of risk-adjusted payments will increase to 30 percent in 2004, 50 percent in 2005, 75 percent in 2006 and full risk adjustment of 100 percent in 2007 and succeeding years. The lack of risk-adjustment data may affect the premium to the M+CO and the physician or health care professional organizations delegated for claims processing. M+COs began submitting risk-adjustment data to CMS after October 1, 2002, for dates of services beginning July 1, 2002, through June 30, 2003. This will determine the payments for 2004. Co-existing Conditions The ICD-9 CM guidelines for co-existing conditions that should be coded for hospital outpatient and physician services are as follows: "Code all documented conditions that coexist at time of encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment."

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Aetna's Medicare+Choice Plans

Physicians and hospital outpatient departments shall not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working" diagnosis. Rather, physicians and hospital outpatient departments shall code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Medical Record Validation CMS will conduct a medical record review to validate the accuracy of the risk-adjustment data submitted by the M+CO. The medical records shall agree to the diagnoses of the hospital outpatient and physician diagnoses provided to the M+CO. The medical record shall be retrievable to validate the diagnosis reported. CMS anticipates adjusting payments to M+COs as a result of up coding or down coding with the results of the calendar year 2003 data validation. Providers of Hospice-Related Services Aetna Golden Medicare Plan and Aetna Golden Choice Plan members may elect to use the hospice benefit in the Original Medicare program instead of their HMO or POS Medicare coverage. Prior to initiating hospice care, the "Election of Benefits" waiver must be signed by the member or his/her representative. When this election is documented, the case should be referred to the Original Medicare hospice provider. Original Medicare will assume financial responsibility on the date the waiver is signed, and reimbursement will be made by Original Medicare directly to the agency. DME will be the responsibility of the hospice provider. The M+C plan remains responsible for payment of those services not related to the terminal illness and additional benefits not covered by Medicare. An example of an additional benefit is the eyeglass reimbursement. For services not related to the terminal illness, inpatient services should be billed to the Medicare Fiscal Intermediary using the condition code 07. For physician services and ancillary services not related to the terminal illness, the physician or other health care professional should bill the Medicare Carrier (as is done for Medicare FFS patients) and use the modifier GW. Attending physician services are billed to the Medicare Carrier with the "GV" modifier, provided they were not furnished under a payment arrangement with the hospice. If another physician covers for the designated attending physician, the services of the substituting physician are billed by the designated attending physician under the reciprocal or locum tenens billing instructions. In such instances, the attending physician bills using the "GV" modifier in conjunction with either "Q5" or "Q6" modifier. Mandatory Generic Drugs (for those members with this benefit) Benefits vary across plan designs. Generic medications are required when available. If a physician believes the member requires a brand-name drug and the physician obtains approval from Aetna Pharmacy Management, the member is only responsible for the applicable brand-name copayment and not the difference in cost between the brand-name and generic drugs. Only physicians can obtain this approval; pharmacists are not eligible to request approval. M+C Organization Obligations The M+CO is prohibited from restricting a physician or health care professional from advising his/her patients about their health status, treatment options, the risks and benefits of those treatment options, and the opportunity to refuse treatment and/or express preferences about future treatment decisions.

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Aetna's Medicare+Choice Plans

Medicare+Choice Member Appeal Rights As a member of the M+C plan, a member has the right to appeal any decision about the plan's failure to pay or provide coverage for what the member believes are covered benefits and services (including non-Medicare covered benefits). The M+C plan has both standard and expedited M+C appeals procedures. Decisions that are commonly appealed include: Disputes involving payment for coverage of temporarily out-of-area renal dialysis services, emergency services, post-stabilization care or urgently needed services. Disputes involving payment for any other health services furnished by a provider or supplier that the member believes are covered by Original Medicare or, if not covered by Original Medicare, should have been reimbursed by the M+C plan. Disputes involving failure of the M+C plan to approve, furnish, arrange for or provide coverage for health care services in a timely manner, or to provide the member with timely notice of an adverse determination, such that a delay would adversely affect the member's health. Discontinuation of coverage of a service, if the member disagrees with the determination that the coverage of service is no longer medically necessary. When rights claimed by a member regarding Medicare covered services covered by the M+C plan are denied, resulting in a dispute that places financial liability on the member. Who May File an Appeal 1. A member 2. The legal representative of a deceased member's estate 3. Someone else may file the appeal for a member on his/her behalf. A member may appoint an individual to act as his/her authorized representative to file the appeal for them by following the steps below: a. Give the M+C plan the member's name, Medicare number and a statement that appoints an individual as the member's representative.

Note: A member may also appoint a physician.

b. The member must sign and date the statement. c. The member's representative must also sign and date this statement unless he/she is an attorney. d. The member must include this signed statement with their appeal. 4. A non-contracted physician or other provider who has furnished the member a service may file a standard appeal of a denied claim if they complete a waiver of payment statement that says they will not bill the member regardless of the outcome of the appeal. M+C Standard Member Appeals The M+C plan must notify the member in writing of any adverse decision (partial or complete). The notice must state the reasons for the denial and also must inform the member of his/her right to an appeal as well as the entire appeals process, including expedited appeals (for denials of requests for services). The member must submit a written request for an appeal to the M+C plan. The member should refer to their Evidence of Coverage for the appropriate M+C plan Medicare Grievance and Appeals Unit address. The member may also request an appeal through the Social Security office (or, if the member is a railroad retirement beneficiary, through a Railroad Retirement Benefits Office). The member must submit the written request within 60 calendar days of the date of the notice of the initial decision.

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Aetna's Medicare+Choice Plans

The M+C plan will conduct an appeal and notify the member in writing of the decision, using the following timeframes: Request for Service. If the appeal is for a denied service, the M+C plan must notify the member of the reconsideration decision as expeditiously as the member's health requires, but no later than 30 calendar days from receipt of the request. The M+C Plan may extend this timeframe by up to 14 calendar days if the member requests the extension or if the plan needs additional information, and the extension of time benefits the member. Request for Payment. If the appeal is for a denied claim, the M+C plan must notify the member of the reconsideration determination no later than 60 calendar days after receiving the request for a reconsideration determination. M+C Expedited Member Appeals A member has the right to request and receive expedited decisions affecting coverage of their medical treatment in time-sensitive situations. An expedited appeal is: an oral or written request from an Medicare member, their authorized representative or a physician (either contracted or non-contracted) for an expedited review of a determination by the M+C plan not to provide coverage of services that the member believes they are entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the member's health); or of a determination to discontinue services when the member believes there is a continuing need for the service. AND, the Medicare member, their authorized representative or physician (contracted or noncontracted) believes the member's health, life or ability to regain maximum function could be jeopardized by the standard 30 calendar day reconsideration process. The process of review and decision is conducted as expeditiously as the member's health requires, not to exceed 72 hours. The M+C plan may extend the 72 hour deadline by up to 14 calendar days if the member requests the extension or if the M+C plan justifies a need for additional information and the delay is in the interest of the member. How to Request an M+C Expedited Member Appeal To request an expedited appeal, the member, their authorized representative or a physician (contracted or non-contracted) may call, write, fax or visit the M+C plan. Telephonic requests are accepted 24 hours a day, 7 days a week. The 72-hour timeframe commences with the M+C plan's receipt of the request.

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Aetna's Medicare+Choice Plans

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