Aetna officelink updates midamerica region

December 2015 • Volume 12, Issue 4
Inside this issue
Updates to our National Precertification List
We're aligning the Aetna NPL and Coventry prior-authorization lists
Coventry medical plans (commercial and Medicare) will move to a National Participating Provider Precertification List (NPL) by April 1, 2016. There is no direct impact for Aetna-based plans. Reminders and updates
These changes t will take effect as noted below:
• Cardiovascular – PCSK9 inhibitors require precertification
- Praluent (alirocumab) – effective August 15, 2015 - Repatha (evolocumab) – effective September 15, 2015 • Technivie (ombitasvir/paritaprevir/ritonavir) and Daklinza (daclatasvir)- effective August 15, 2015 • Temodar (temozolomide) – oral formulation only; Xeloda (capecitabine); Nuwiq (simoctocog alfa); Cyramza (ramucirumab); and Granulocyte-colony stimulating factors – effective January 1, 2016 Options to reach us
You can find more information abou under the "General information" section of th.
Select "Log In/Register" Member ID card on smartphone is valid
If you have questions after viewing the information online, call us: If Aetna members show you their ID card on their smartphone or other mobile device, your office or facility should accept that as valid proof of insurance coverage.
• 1-800-624-0756 for
HMO-based and Medicare The digital ID card is an electronic version of the member's ID card. It still allows you to easily get all of the information you need.
• 1-888-MDAetna
You should expect to see an increasing number of members using this technology in the (1-888-632-3862) for all
future. Of course, many members will continue to use ID cards in plastic or paper formats.
other benefits plans 00.22.809.1 MA (11/15) Policy and Coding Updates
Clinical payment, coding and policy changes
We regularly adjust our clinical, payment and coding policy positions as part of our ongoing policy review processes. In developing our policies, we may consult with external professional organizations, medical societies and the independent Physician Advisory Board, which advises us on issues of importance to physicians. The chart below outlines coding and policy changes: 86003 – Allergen specific
We will al ow 86003 30 times per year. This frequency limit is based on lge; quantitative or
a rolling year (12 months), from the time the service is first rendered. semiquantitative, each allergen
Precertification required for Medicare Part B immunologic drugs
Part B immunologic drugs will need precertification starting January 1, 2016. Providers will need to consider recommending the lower cost drug in this category where appropriate. During the precertification review of this drug, we'll determine if:• The member meets the clinical criteria for treatment• The lower cost drug is prescribed for treatment • The lower cost drug is not prescribed for treatment, the reason for not using itWe identify the lower cost brands within a drug class where there is no evidence that any one brand is superior for medically necessary indications. If a provider doesn't use the lower cost drug, and there is no rationale why the lower cost drug isn't appropriate, then we would encourage a peer-to-peer discussion with an Aetna medical director. During the coverage review, we offer the peer-to-peer discussion for any likely denial. We'll issue the denial letter only when the peer-to-peer process does not change our decision, or if the peer-to-peer request doesn't occur in a timely manner (based upon CMS turnaround times). After the denial letter is sent, an appeal will be needed for us to reconsider approval of coverage.
We did it – we're all using new ICD-10 codes now
Since October 1, 2015, you've used the new ICD-10 code set. And we're processing your claims with these codes.
Using these codes will help us better understand your patient's condition and treatment. And it should lead to better care and outcomes.
We're all in this together. Keep using these resources for any ongoing questions you have:• The • Our ageCall us if you have questions that the above resources can't answer.
Aetna OfficeLink Updates December 2015
Office News
Improving our customer service to you
We improved our customer service model to give you better service. When you need to reach us, use the options below instead
of calling your local network contact. These options are easy to use and will save you time.
Go to thage on our website• These tools will help you with administrative tasks, like electronic patient referrals and e-prescribing. • E-mail us via the "contact" link if you can't find what you need.
Or, log into NaviNet, ouhere you can:• Get information on benefits, referrals and claims• Use our provider payment estimator and electronic claims system• Update your registration, billing and user profile information • See your patients' personal health records to help you better coordinate their care Automated phone system
With our automated system, you can determine if a procedure needs precertification, get a patient's copay or claims status.
If you can't resolve your issue through the system, our provider service center staff can help at:
• 1-800-624-0756 for HMO-based and Medicare Advantage plans.
• 1-888-MDAetna (1-888-632-3862) for all other plans.
Another great resource i. This site provides:• User-friendly navigation and search• A variety of office staff courses to help ease administration• Effortless "Share with a colleague" functionality• Online, live webinars and recorded events• Helpful reference tools to make your job easier, and much more Get precert forms on our website
After you send an electronic precert request, we may ask you to complete a form to give us more information. In the past, we faxed you the right form. Now you can get the forms from the page of our website. Click on the "+" next to "Medical Precertification" or "Behavioral Health Precertification" for the form you need.
You can also get to the page from our . Log in and look for "Precert Information Request Forms" in the Precertification menu.
When you return the form to us, include the "administrative reference number" you received on your electronic precert response.
Aetna OfficeLink Updates December 2015
New health insurance exchanges for 2016: Kentucky and Illinois
Beginning January 1, 2016, Aetna will offer Qualified Health Plans (QHPs) in Kentucky and Illinois.
Referrals
Plan Type
for emergencies Oldham, Access (HNOnly). for emergencies Kane, Lake and How to identify members
"QHP" will be listed on member ID cards. This means the plan
• Tier 1 providers (lowest cost providers) are listed on meets certain requirements under the Affordable Care Act the "Best Results for Your Plan" tab. Tier 2 providers and is certified by the Centers for Medicare & Medicaid (members may pay more to see these providers) are Services. You'll follow the same processes you already use to listed on the "All Other Results" tab.
check eligibility, benefits and submit claims. Referrals should be made to network QHP providers.
We're here to help
How to find network providers
If you have questions, call our Provider Service Center at
1-888-632-3862. For precertification questions in Kentucky,
call 1-844-281-8247. You can also go to th
• Select "Qualified Health Plans (QHPs)"on the left menu. Click on "QHP DocFind" link.
website. Or, go to th • Select your state of residence. Then select the plan, click "continue," and complete your provider search.
Use secure site to update data about your office
To update your office's demographic information, go to our to maintain accurate directories. Having your up-to-date information allows us to do that.
• New e-mail addresses • New mailing addresses You also can do most electronic transactions through this • New phone or fax numbers website. This includes submitting claims, checking patient • Name changes due to marriage or another life event benefits and eligibility, and requesting precertifications.
If you've been calling our Provider Service Center to make NaviNet Security Officers have access to Aetna's "Update these changes, we ask you to use the secure site instead. The Provider Profiles" function, through which they can submit site lets you confirm the information you submit. It prevents demographic changes. They also can authorize other users' unauthorized individuals from submitting wrong information access to this feature as appropriate. To use the secure about your office or facility.
website you musirst.
The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage plans and Qualified Health Plans (QHPs) Aetna OfficeLink Updates December 2015
2015 Commercial Risk Adjustment program
The objective of this program is to identify patients of individual or small group plans either on or off the health insurance exchange who currently have or are at risk for acute and chronic conditions. The goal is to help manage patient care through proper medical record documentation, coding and billing.
To help these efforts, you can:• Schedule health assessments for your Aetna/Innovation Health patients. • Provide medical record to our vendors: Your Home Advantage (YHA), Episource, Verisk and Arro Health• Evaluate health conditions and document them in medical records and claims Member assessment
Our member gap magnifier report identifies patients with conditions requiring management. It also lists patients at risk for
conditions. You can get a copy of this report during a meeting with one of our nurses.
The health assessment identifies current or suspected conditions. Your patients can schedule a free assessment with our vendors,
YHA or MedXM®. Or, they can schedule one at your office, which may be subject to cost share. We'll share the information from
the vendors with you to coordinate care. Health assessments performed by our vendors don't replace your care.
Medical record requests
Our vendors will retrieve records on our behalf, so submit them upon request. It helps identify patients with documented medical
conditions that qualify for risk adjustment.
Improve your documentation
Remember to evaluate and document the treatment of all conditions at each encounter for each date of service. Then submit by
paper or electronic claim.
Our Office Manual keeps you informed
Aetna's (Manual) is available on our website. The Manual has information to help you serve your patients efficiently and accurately, including:• Clinical Practice Guidelines and Preventive Service Guidelines. These can also be found on our Once logged in, select "Clinical Resources" from the Aetna Support Center.
• Policies and procedures. • Patient management and acute care. • Case management and disease management programs.
• Special member programs/resources, including the Program, • Member rights and responsibilities.
• What utilization management is and how decisions are made, including our policy against financial compensation.
• How our Quality Management program can help you and your patients. We integrate quality management and metrics into all that we do. You can find details on the program goals and how we're progressing toward those goals.
To access the anual, once on the website select "Physicians & Providers," then "Practice Resources." If you don't have Internet access, call our Provider Service Center for a paper copy.
Medical record requests
Our vendors will retrieve records on our behalf, so submit them upon request. It helps identify patients with documented medical
conditions that qualify for risk adjustment.
Improve your documentation
Remember to evaluate and document the treatment of all conditions at each encounter for each date of service. Then submit by
paper or electronic claim.
Aetna OfficeLink Updates December 2015
New and updated courses for physicians, nurses and office staff
Visitg in or registration may be required for some content.
Reference Tools:
New - Medicare Supplement Plans and Aetna Supplemental Retiree Medical Plans
New - Provider and facility participation criteria
Updated - Aetna Signature Administrators®
2015 Centers for Medicare & Medicaid Services compliance requirements
Time is running out. Complete your annual Medicare Attestation today.
Through your Aetna and/or Coventry provider contract, you must annually meet Centers for Medicare & Medicare Services (CMS) compliance requirements for First Tier, Downstream and Related Entities (FDRs). These program compliance requirements include:• General compliance and fraud, waste and abuse (FWA)* training • Code of conduct/compliance policies dissemination • Exclusion list screenings • Reporting mechanisms for potential FWA and compliance issues • Offshore protected health information operation reporting • Downstream entity oversight Complete FDR attestation by December 31, 2015.
To avoid changes in participation status, an authorized representative of your organization must complete and submit your 2015
Medicare Attestation. You can submit your attestation within the Aetna Provider Education Portal by following these steps:
1. Log In or register a.
2. Type "attestation" in the search field and click "go."
3. Select "2015 Aetna Medicare Attestation" (required log in).
Failure to meet the FDR Compliance requirements by December 31, 2015 may impact your participation status.
FDR requirement changes coming January 1, 2016
CMS recently issued a Final Rule that aims to reduce the training burden for FDRs. Medicare providers must use the CMS
training to meet general compliance and FWA training requirements. For more information on the change, see the October 2015

Questions?
For more details on the FDR program compliance requirements, visit .
Then search "attestation." Or, you can call our Provider Service Center at 1-800-624-0756.
*You only need to complete one attestation to meet both Aetna and Coventry compliance obligations.
Aetna OfficeLink Updates December 2015

Take our Compassionate Care Program course
Patients with advanced illness face many medical and emotional issues. We've developed a 15-minute training course so you can learn more about the Aetna Compassionate Care Program. Links to informational flyers for you and your patients are included.
The Aetna Compassionate Care Program is an enhanced care management program that can help your patients make choices that are best for them. It's free to our Medicare Advantage members as part of their benefits.
You'll find the course anter "Advanced Illness" in the Search box and click "GO." Patient support and education
Our nurse case managers and social workers understand the physical, emotional, spiritual and cultural needs of patients dealing
with advanced illness. They're available by phone to support and educate your patients, their families, and their caregivers.
Aetna OfficeLink Updates December 2015

Use our Aetna Medicare retail pharmacy network
Aetna's retail Medicare pharmacy network includes over 60,000 pharmacies, including more than 30,000 preferred pharmacies.
This network will be available to nearly all of your patients enrolled in Aetna's Medicare Advantage (MAPD) and Prescription Drug Plans (PDP) in 2016. You can help your Aetna Medicare patients save money by referring them to the preferred network, where copays are typically lower for drugs on generic tiers. They can go t for the list of preferred pharmacies in this network. Our preferred pharmacies include:
• Walgreens
• Walmart
• Costco
• Kroger
• Safeway
• Many more national and regional chains
• Thousands of local independent pharmacies
For help finding a preferred pharmacy, members can call the Member Services number on the back of their ID card.
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.
• Go to ou• Go to ouage for the Commercial Preferred Drug Lists
For a paper copy of these lists, call the Aetna Pharmacy Management Provider Help Line at 1-800-AETNA RX (1-800-238-6279).
Aetna OfficeLink Updates December 2015
Route this publication to: Office Manager Referral and Precertification Staff Business Staff Front Desk Staff Medical Records/Medical Assistants Primary Care Physicians Specialists Physician Assistants/Clinical Nurse Specialists Nurses Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies,
including Aetna Life Insurance Company and its affiliates (Aetna).
Innovation Health Insurance Company and Innovation Health Plan, Inc. (Innovation Health) are affiliates of Aetna Life
Insurance Company (Aetna) and its affiliates. Aetna and its affiliates provide certain management services for Innovation
Health, including precertification.
The information and/or programs described in this newsletter may not necessarily apply to all services in this region. Contact your
Aetna network representative to find out what is available in your local network. Application of copayments and/or coinsurance may vary by plan design. This newsletter is provided solely for your information and is not intended as legal advice. If you have any questions concerning the application or interpretation of any law mentioned in this newsletter, please contact your attorney.
2015 Aetna Inc.
00.22.809.1 MA (11/15)

Source: http://www.limamemorial.org/media/1437/aetna-office-link-updates-dec2015.pdf